THE 
PRINCIPLES AND PRACTICE 
OF 
SURGERY, 
BEING 
TREATISE ON SURGICAL DISEASES AND INJURIES. 
bv 
D. HAYES AGNEW, M.D., LL.D., 
PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF PENNSYLVANIA. 
PROFUSELY ILLUSTRATED. 
VOL. IL 
PHILADELPHIA: 
J. B. LIPPINCOTT & CO. 
LONDON: 16 SOUTHAMPTON STREET, COVENT GARDEN. 
1881. Copyright, 1881, by J. B. Lippincott & Co. PREFACE. 
In submitting to the profession the second volume of my work on the 
Principles and Practice of Surgery, I wish to express my sense of obligation 
to Dr. J. William White for his valuable services in revising and correcting 
o O 
the proof-sheets while passing through the press. 
For the preparation of the Index I desire to thank Dr. Charles Baum, 
to whom, as well as to Dr. Charles Hunter, I am also indebted for the col- 
lection of much statistical matter. 
The section on Surgical Diseases of the Teeth was kindly reviewed by 
Dr. James W. White, from whom I received many useful suggestions. 
To the critical acumen of Mr. McCrecry, proof-reader for the publishers, 
I am indebted for the correction of numerous verbal and other inaccuracies. 
The original cuts contained in the volume were drawn by Mr. Faber. For 
those obtained from other sources I have endeavored, wherever possible, to 
give credit. 
Mr. Gemrig and Mr. Kolbe, surgical cutlers of Philadelphia, furnished 
many of the cuts of instruments and other surgical appliances. 
The third volume, which, when published, will complete the work, is in 
process of rapid preparation. 
1611 Chestnut Street, Philadelphia. 
D. HAYES AGNEW. CONTENTS OF VOLUME II. 
CHAPTER XI. 
PAGE 
Definition-Classification-Causes-Symptoms-Diagnosis-Pathological Effects- 
Prognosis-Treatment-Means employed in Reduction-Manipulation-Anaes- 
thetics-Force-Position of the Patient-Extension and Counter-Extension-Mode 
of Using Force-After-Treatment-Complicated-Treatment-Compound-Treat- 
ment-Old-Laceration of Vessels-Laceration of Muscles-Laceration of Nerves 
-Abscesses-Congenital Dislocations--Traumatic-Nervous-Defects of Foetal 
Development-Treatment-Special Dislocations-Of the Inferior Maxillary Bone 
-Causes-Mechanism-Bilateral-U nilateral-Subluxations - Diagnosis - Prog- 
nosis-Treatment-Barton's Bandage-Noisy Movements of the Temporo-Max- 
illary Joints-Cramp of the Jaw-Congenital Dislocations-Ribs and the Costal 
Cartilages-Costo-Vertebral-Costo-Chondral and Chondro-Sternal-Chondral- 
Bones of the Sternum-Ensiform Cartilage-Vertebrae-Cervico-Vertebrae-Table 
of Cervical Dislocations-Below the Second Cervical Vertebra-Above the Second 
Cervical Vertebra-Occipito-Atloid-Atlo-Axoid-Dorsal Vertebrae-Bones of the 
Upper Extremity-Shoulder-Clavicle-Forward-Backward-Upward-Simul- 
taneous Dislocation of both Sternal and Acromial End of the Clavicle-Scapula 
-Downward-Upward-First Variety-Second Variety-Inferior Angle of the 
Scapula-Humerus-Frequency-Varieties-Downward-Forward-Backward, or 
Subspinous-Partial Luxations, or Subluxations-Common Signs of Scapulo- 
Humeral Dislocations-Signs of Varieties contrasted-Diagnosis-Treatment- 
Reduction by Manipulation-Extension and Counter-Extension-Heel in the 
Axilla-Arm Parallel with the Side of the Head and Face-Arm at a Right Angle 
with the Body-N. Smith's Method-Sir Astley Cooper's Method-Pulleys-Com- 
plications-Old Unreduced Luxations of the Humerus-Rupture of the Axillary 
Artery-Treatment-Laceration of Axillary Veins-Injury of Nerves-Fracture 
-Diffused Abscess-Fracture of Glenoid Cavity-Fracture simultaneous with 
Dislocation of Humerus-Compound-Fracture of Ribs-Simultaneous Disloca- 
tion of both Humeri-Congenital Dislocations of Humerus-Bones of Forearm- 
Radio-Humeral-Forward-Backward-Outward-Ulna from Humerus-Radius 
and Ulna-Backward-Diagnosis-Treatment-Complications-Forward-Lateral 
-Compound-Inferior Radio-Ulnar Articulation-Backward-Forward-Partial 
-Hand-Carpus-Backward-Forward-Compound-Congenital-Carpal Bones 
-Metacarpus-Metacarpal Bone of Thumb-Thumb-Proximal Phalanx of 
Thumb-Backward-Difficulties in Reduction-Reduction-Manipulation-Trac- 
tion Forceps-Forward-Second Phalanx of Thumb--Fingers-Metacarpo-Pha- 
langeal-Phalanges-Compound Dislocations of Thumb and Fingers-Bones of 
the Pelvis-Coccyx-Bones of the Lower Extremity-Hip or Thigh-Varieties- 
Relative Frequency-Difficulties of Reduction-Y Ligament-Upward and Back- 
ward, or Iliac-Diagnosis-Upward and Backward, or Ischiatic-Reduction of 
Iliac and Ischiatic-Manipulation-Extension and Counter-Extension-Pulleys- 
Downward and Forward-Reduction by Manipulation-Pulleys-Upward and 
Forward - Reduction by Manipulation - Extension and Counter-Extension - 
Anomalous Dislocations of Head of Femur-Table-Partial or Incomplete Luxa- 
tions of Hip-Complications-Old-Accidents attending Reduction of the Hip- 
Joint-Congenital, of Hip-Treatment-Patella-Outward - Inward-Vertical 
or Axial-Treatment-Upward - Downward - Congenital - Knee - Forward - 
Backward-Lateral-External Rotatory-Displacement of the Semilunar Carti- 
lages-Complicated, of Knee-Compound-Congenital-Foot or Ankle-Forward 
-Backward-Outward-Pott's Fracture, with Dislocation-Treatment-Inward 
VOL. II.- 1 
DISLOCATIONS. 
1 2 
CONTENTS OF VOLUME II. 
PAGE 
-Compound-Treatment-Fibula? or Peroneo-Tibial-Upper Extremity-Lower 
Extremity-Tarsus-Astragalus-Forward-Backward-Irreducible, of Astrag- 
alus-Subastragaloid-Treatment-Unusual, of Astragalus-Os Calcis-Scaphoid 
Bone-Cuboid Bone-Cuneiform Bones-Metatarsus-Treatment-Toes-Com- 
pound Treatment 17 
CHAPTER XII. 
DISEASES OF THE JOINTS. 
Movable Bodies within the Joints-Symptoms-Treatment-Results of Operations- 
Anatomical Summary of Components of a Joint-Traumatic Articular Disease- 
Sprains and Contusions-Sprains-Contusion or Concussion-Symptoms-Diag- 
nosis-Treatment-Irritable Joint-Treatment-Wounds of the Joints-Treat- 
ment - Synovitis - Symptoms - Pathology - Treatment - Chronic Synovitis - 
Dropsy of the Joint-Treatment-Syphilitic Synovitis-Passive Synovitis-Anchy- 
losis-Complete or True-Incomplete or False-Diagnosis-Treatment-Apparatus 
for Anchylosis-Subcutaneous Osteotomy-Fibroid Formations in the Synovial 
Membrane-Cartilage Degeneration-Fibrous-Changes in the Articular Ends of 
Bones in Arthritis-Theories of Strumous or Scrofulous Disease of the Joints- 
Arthritis-Symptoms-Diagnosis-Pathology-Changes in the Synovial Mem- 
brane- Symptoms - Treatment - Articular Disease arising from Constitutional 
Causes-Osteo-, Dry, or Rheumatoid Arthritis-Osteo-Arthritis of Special Joints 
-Pathological Changes-Treatment-Strumous Inflammation of the Articular 
Extremities of Bones-Symptoms-Treatment-Diseases of Special Joints arising 
from Constitutional Causes-Morbus Coxarius, Coxalgia, or Hip-Joint Disease- 
Stages-Explanation of Symptomatic Phenomena-Second and Third Stages con- 
trasted - Causes - Pathology - Differential Diagnosis - Prognosis -Treatment- 
Mechanical Supports in Coxalgia-Conditions requiring Operative Measures- 
-Fibrous Anchylosis-Bony Anchylosis-Adams's Operation in Coxalgia-Con- 
ditions for and against Excision in Coxalgia-Knee-Joint Disease, or ""White 
Swelling"-Causes-Symptoms-Prognosis-Treatment-Mechanical Apparatus 
- Excision-Amputation-Ankle-Joint Disease-Causes-Symptoms-Prognosis 
-Treatment-Gouging Operations-Amputation-Excision-Arthritis of Calcareo- 
Astragaloid and Astragalo-Scaphoid Joints-Arthritis of Tarso-Metatarsal Joints 
-Arthritis of Metatarso-Phalangeal Joints-Arthritis of the Occipito-Atloid and 
Atlo-Axoid Articulations-Arthritis of the Sacro-Iliac Articulation-Causes- 
Pathology-Symptoms-Differential Diagnosis-Prognosis-Treatment-Sterno- 
clavicular and Acromio-Clavicular Arthritis-Arthritis of Joints of the Upper 
Extremities-Shoulder-Joint-Elbow-Joint-Wrist and Carpal Disease-Nervous 
Diseases of Joint-Pseudarthritis-Symptoms-Causes-Differential Diagnosis- 
Anaesthetics-Treatment 127 
CHAPTER XIII. 
EXCISION OF JOINTS AND BONES. 
Excision-Definition-History-Conditions requiring Excision in the Continuity of 
Bones-Contiguity-Contra-Indications - Reparation following - Instruments- 
Rules to be observed-Excision of Special Joints and Bones-Shoulder-Joint- 
Operation -Usefulness of Arm - History - Results - Elbow-Joint-Operation - 
Dressing-Results-History-Radio-Carpal, orWrist-Joint- Operation-Lister's- 
Dressing-Results-History-Portions of Bones of the Hand-Sternum-Ribs and 
their Cartilages-Operation-History-Results-Hip-Joint-Operation-Dressing 
-Results - History - Knee-Joint - Operation - Dressing - Results - Deductions 
from Results - History - Ankle-Joint - Operation - Dressing - Subperiosteal 
Method-Results-Comparison with Amputation-History-Clavicle-Operation 
-Dressing-Usefulness of Arm-History-Table of Cases-Scapula-Acromion 
Process-Subperiosteal Method - Dressing - History and Results - Excision of 
Scapula following Amputations at the Shoulder-Joint-Excision in the Conti- 
nuity of the Humerus-Operation-Results and Indications-Bones of Forearm 
-Operation-Dressing-History-Bones of Lower Extremity in their Continuity 
-Femur-Femur at Trochanter Major-Patella-Bones of the Leg-Tibia-Sub- 
periosteal-Operation-Results-Fibula-Operation-Tarsal Bones-Astragalus- 
Operation-Dressing-Results-History-Os Calcis-Operation-Subperiosteal- 
Results-Calcaneum and Astragalus-Operation-History-Excision of Cuboid, 
Scaphoid, and Cuneiform Bones-Results-Metatarsal Bones-Toes-Results . 206 CONTENTS OF VOLUME IT. 
3 
CHAPTER XIV. 
CONSIDERATION OF SUBJECTS CONNECTED WITH MINOR SURGERY-ON THE USE 
OF THE KNIFE-VENESECTION. 
PAGE 
Positions of the Knife-Manner of Dividing Parts-Form of Incisions-Hemor- 
rhage-Punctures-Acupuncture-Venesection-Superficial Surgical Anatomy at 
the Bend of the Arm-Instruments-Operation at the Bend of the Arm-On the 
Leg 261 
CHAPTER XV. 
GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS. 
Preparation of Patients-Conditions influencing Results-Apartments-Ventilation 
and Temperature-Assistants-Time to Perform-Preparations-Table-Hemor- 
rhage-Dressing-After-Treatment-Diet-Medication-Removal of Dressings- 
Dressing or Hospital Wagon-Accidents during and after Operations-Exhaus- 
tion-Hemorrhage-Entrance of Air into a Vein-Embolism-Secondary Hemor- 
rhage-Mania a Potu-Hysteroidal Delirium-Tetanus-Retention of Urine- 
Muscular Spasm . 268 
CHAPTER XVI. 
ANAESTHETICS. 
History-Effect of Anaesthetics upon the Mortality after Operations-Precautions in 
Using-Supposed Contra-Indications-General Anaesthetics-Ether-Chloroform 
-Bichloride of Methylene-Ethidene-Nitrous Oxide-Respiratory Anaesthesia- 
Comparison of Anaesthetics-Local Anaesthetics-Frigoritic Mixture-Ether- 
Rhigolene-Carbolic Acid 280 
CHAPTER XVII. 
AMPUTATION. 
Definition-Circumstances demanding-Injuries and Diseases of the Soft Parts-In- 
juries and Diseases of the Bones-Injuries and Diseases of the Joints-Deformities 
-Aneurism-Mortification-Malformations-Period for Amputation-Primary- 
Intermediary-Secondary-History-Various Methods-Tegumentary-Circular 
Flaps-Oval Flaps-Single Flap-Musculo-TegumentaryFlap-Bi-Musculo-Tegu- 
mentary-Author's Modification-Oval Method-Semi-Musculo-Tegumentary-■ 
Quadrangular-History-Comparison of Methods-Conclusions from Comparison- 
Operation of Amputation-Instruments-Position of Patient-Assistants-Control 
of the Circulation-Ligation of Arteries-Closing the Stump-Dressings compared 
-Removal of Dressings-Complications following-Primary Local Complications 
-Hemorrhage-Spasm of Stump-Inflammation, Suppuration, and Mortification 
-Protrusion of Bone-Secondary Complications-Secondary Hemorrhage-Osteo- 
myelitis and Necrosis-Conical Stump-Bulbous Enlargement of Bone-Neuralgia 
-Contraction of Tendons-Aneurismal Varix-Degeneration of Stumps-Bursa- 
Simultaneous Amputations-Table of Multiple-Intra-Uterine-Artificial Limbs 
-Statistics of Amputation-Special Amputations-Upper Extremity-Phalanges 
-Metacarpo-Phalangeal-Thumb-Metacarpal Bones-Wrist-Results-Forearm 
-Elbow-Arm-Shoulder-Above Shoulder-Results-Lower Extremity-Pha- 
langes-Metatarsal -Tarso-Metatarsal-Medio-Tarsal - Subastragaloid-Ankle- 
Leg-Upper Third-Knee-Thigh-Condyloid-Supra-Condyloid-Shaft of Femur 
-Through Trochanteric Part of Femur-Hip-Oval Tegumentary Flaps-Mus- 
culo-Cutaneous Flap-History-Results ......... 298 4 
CONTENTS OF VOLUME JI. 
CHAPTER XVIII. 
SHOCK-TRAUMATIC FEVER. 
PAGE 
Definition-Symptoms-Delirium accompanying-Secondary-Causes-Intensity- 
Nature-Secondary or Demote Effects-Prognosis-Post-Mortem Appearances- 
Modes of Death-Treatment-Operations during Shock-Traumatic Infective Fever 
-Simple-Treatment-Secondary-Complicated, or Pyaemia-Theories concerning 
-Morbid Anatomy-Predisposing Causes-Symptoms-Fever Charts-Differen- 
tial Diagnosis-Prognosis-Treatment-Prophylaxis at the Pennsylvania Hospital. 876 
CHAPTER XIX. 
FURUNCULUS, PHLEGMON, OR BOIL. 
Definition-Symptoms-Treatment-Anthrax, or Carbuncle-Causes-Symptoms- 
Diagnosis-Prognosis-Anatomical Structure-Treatment-Erysipelas-Predis- 
posing Causes-Exciting Causes-Cutaneous-Symptoms-Cellulo-Cutaneous, or 
Phlegmonous-Subcutaneous-Laryngeal-Synovial and Serous Membranes- 
Duration-Explanation of Phenomena-Post-Mortem Appearances-Diagnosis- 
Prognosis-Erysipelas in the Surgical Wards at St. Bartholomew's Hospital- 
Treatment-General-Local-Burns from Artificial and Solar Heat-Degrees- 
Shock-Inflammatory Fever-Prognosis-Cicatricial Contractions-Treatment- 
Constitutional-Local-Of Cicatrices-Frost-Bite, Chilblain, or Pernio-Degrees 
-Action of Cold-Treatment-Sunburn-Lightning-Stroke .... 397 
CHAPTER XX. 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Injuries and Diseases of the Penis-Wounds of the Integument-Diseases of the 
Integument-Hypertrophy-Phimosis-Treatment - Circumcision-Dilatation- 
Incision-Acquired Phimosis-Treatment-Paraphimosis-Short. Fraenum Prae- 
putii-Absence of Fraenum-Epithelioma of Prepuce-Ablation of Penis-In- 
flammation of Penis-Fracture-Curvature-Luxation-Calcification-Priapism- 
Warts-Wounds of Penis-Wounds of Corpus Spongiosum and Urethra-Lacer- 
ation of Urethra-Urethral Fever-Urethral Fistula-Treatment-Urethroplasty 
-Malformations of the Urethra-Hypospadias-Epispadias-Foreign Bodies in 
the Urethra-Symptoms-Treatment-Tumors of the Urethra-Treatment-Vas- 
cular Growths-Villous or Papillomatous Growths-Urethritis-Non-Specific- 
Specific Urethritis, or Gonorrhoea-Causes-Nature of the Virus-Symptoms- 
Pathology - Diagnosis - Treatment - Abortive - Curative - Injections - Com- 
plications-Treatment-Consequences of Gonorrhoea-Gleet-Granular Urethritis 
-Gonorrhoeal Ophthalmia-Gonorrhoeal Rheumatism-Diagnosis-Treatment- 
Irritable Bladder-Neuralgia of Urethra-Stricture of Urethra-Varieties - 
Position-Classification-Pathology-Symptoms -Diagnosis - Sequels of Stric- 
ture-Treatment-Dilatation-Divulsion-Internal Urethrotomy, or Incision- 
External Urethrotomy on a Guide-External Urethrotomy without a Guide, 
or Perineal Section-Subcutaneous Urethrotomy-Diseases of the Prostate Body 
- Inflammation - Acute - Diagnosis -Treatment - Chronic Prostatitis -Treat- 
ment-Prostatic Abscess-Abscess External to the Prostate-Prostat orrhoea- 
Hypertrophy of the Prostate-Frequency-Pathology-Symptoms-Diagnosis- 
Evil Effects-Treatment-Prostatic Calculi-Cheesy Deposits-Cancer-Cysts- 
Hemorrhage-Retention of Urine-Symptoms-Diagnosis-Causes-Treatment- 
Forced Catheterization-Tapping the Bladder-Diseases and Injuries of the Scro- 
tum-Wounds-Eczema-Parasites-Varicose Veins-Pneumatocele, or Emphy- 
sema-(Edema-Inflammation -Mortification-Redundancy-Tumors - Cystie:- 
Adipose-Fibrous-Enchondroma-Scrotal Calculi-Elephantiasis Scroti-Lymph 
-Epithelioma-Cystitis-Acute-Symptoms-Diagnosis-Treatment-Chronic- 
Treatment-Suppuration of Bladder-Abscess-Ulceration-Gangrene-Hypertro- 
phy-Atrophy-Vesical Neuroses-Recto-Vesical Fistula-Vesieo-Pubic or 1 ngui- 
nal Fistulae-Varices-Haunaturia-Diagnosis-Treatment-Adynamia and Paral- 
ysis of Bladder-Incontinence of Urine-Tumors of Bladder-Fibroma-Villous CONTENTS OF VOLUME II. 
5 
PAGE 
Fibroma, or Papilloma-Polypoid Fibroma-Papillary Adenoma-Carcinoma- 
Sarcoma-Tubercle-Catbeterism-Catheters-Catheterism in Female-Affections 
of the Spermatic Cord-Wounds-Rupture of Vas Deferens-Inflammation-Fatty 
Tumors-Carcinoma-Spasmodic Retraction-Diffused Hydrocele-Encysted Hy- 
drocele-Congenital Hydrocele-Hsematocele-Varicocele-Absence of Testicles- 
Hydrocele of Tunica Vaginalis Testis-Encysted-Differential Diagnosis-Treat- 
ment-Infantile-Encysted-Hydrocele of the Inguinal Canal-Hydrocele of Sac of 
Hernia-Hydrocele in Female-Haematocele-Inflammation of Testicle-Epidid- 
ymitis-Acute Orchitis-Pathology-Chronic Orchitis-Syphilitic-Tubercular or 
Strumous-Fungus of Testicle-Encephaloid Disease-Differential Diagnosis- 
Treatment-Sarcoma-Lymphadenoma-Cystic Disease-Enchondroma-Myoma 
-Calcareous Deposits in the Testicle-Fibroma-Irritable Testicle-Neuralgia-- 
Hypertrophy-Atrophy-Dermoid Cysts-Entozoa-Castration-Impotence-Fic- 
titious or Pseudo-Impotence-Sterility-Spermatorrhoea-Congenital Defects of the 
Bladder-Supernumerary-Malposition, or Hernia of-Exstrophy-The Urine - 
Normal-Pathological Changes-Tests-Urinary Deposits-Uric Acid-Urates- 
Oxalate of Lime -Phosphatic-Cystine-Urinary Calculus-Characteristics-Vari- 
eties-Tests-Symptoms-Rational-Physical-Sounding for Stone-Fallacy-Ex- 
ploration of Female Bladder-Pathological Changes-Treatment of Vesical Calcu- 
lus-Local Solvents-Extraction-Lithotrity-Cases suited for-Preparatory Treat- 
ment-Operation-Cautions-Removal of Debris by Evacuators-Bigelow's Method 
-Complications-Sequences-Results-Lithotomy-Il istory-Preparation of the 
Patient-Lateral-Surgical Anatomy of Male Perineum-Instruments-Position 
during Operation-Gorget-Extraction-Washing the Bladder-Lithotomy in 
Children - Difficulties - Causes delaying the Extraction of Stone - Accidents 
during-Accidents following-Mortality-Relapse-Median-Table of Cases- 
Modifications -Medio-Lateral -Bilateral-Recto-Vesical - Supra-Pubic - Opera- 
tion-Compared with Lateral-Rules for Dealing with Vesical Calculus-Lithot- 
omy in the Female-Symptoms-Treatment-Dilatation-Lithotrity-Urethral 
Lithotomy-Vaginal-Diseases of the Kidneys and Ureters-Anomalies-Float- 
ing, or Movable-Nephritis-Acute-Chronic-Pyelitis-Abscess, or Pyonephrosis 
-Perinephritic Abscess-Hydronephrosis-Renal Calculus-Colic-Hsematuria- 
Cysts-Parasitic Disease-Tuberculosis-Carcinoma-Nephrotomy-Abdominal- 
Table of Cases 424 
CHAPTER XXI. 
SURGICAL DISEASES OF WOMEN. 
Of the External Genitals-Adhesion of the Labia-Wounds-Contusions-Puden- 
dal Haematocele, or Thrombus-Abscess-(Edema-Gangrene-Warts-Epitheli- 
oma-Tumors -Fibrous-Adipose-Sebaceous-Cystic-Myxomatous-Clitoris- 
Hypertrophied-Clitoridectomy-Pruritus of the Vulva-Hymen-Vaginismus- 
Lacerations of the Perineum-Causes-Varieties-Evil Effects-Changes follow- 
ing-Time to Operate-Mode of Operation-Preparation-After-Treatment-Mal- 
formations of the Vagina-Incomplete-Absence of-External Closure-Acquired 
Stenosis and Atresia-Stricture-Atresia-Retained Menses-Fissure-Ulceration 
-Prolapse-Tumors-Cystic-Fibrous -Papillomata-Epithelioma-Rodent Ul- 
cer-Gonorrhoea-Symptoms-Diagnosis - Treatment-Complications - Granular 
Vaginitis -Vesico-Vaginal Fistula - Causes - Classification - Characteristics - 
Symptoms-Treatment - Preparation - Operation-After-Treatment - Sequels - 
Complications-Utero-Vesical Fistula-Vesico-Utero-Vaginal Fistula-Surgical 
Affections of the Uterus-Preliminary Observations-Malpositions-Procidentia 
Uteri-Treatment, Mechanical-Operative-Retroversion-Anteversion-Uterine 
Flexions-Lateral-Laceration of the Cervix Uteri-Inversion of the Uterus- 
Amputation-Dysmenorrhoea-Tumors of the Uterus-Myo-Fibromata-Pathol- 
ogy-Causes-Symptoms-Diagnosis-Course-Treatment-Enucleation-Ecrase- 
ment-Incision-Results-Cysto-Fibromata-Uterine Polypi-Varieties-Symp- 
toms-Treatment-Carcinoma of the Uterus-Sarcoma-Elongation of Cervix 
Uteri-Extirpation of the Uterus-Through the Abdomen-Through the Vagina 
-Diseases of the Ovaries-Ovaritis-Displacements-Oophorectomy, or Spaying, 
Battey's Operation-Abdominal-Vaginal-Tables of Cases-Results-Tumors of 
the Ovaries-Cystomata-Causes-Symptoms-Diagnosis-Diagnostic Tapping-• 
Duration - Treatment - Tappi ng - Drainage - Inj ection - Incision - Excision- 
Ovariotomy-History-Operation-Preparation-Instruments-Assistants-After- 
Treatment-Analysis of Cases-Hydrops Tubarum, Hydrosalpinx, or Tubal 
Dropsy-Cysts of the Broad Ligament-Dermoid Cysts-Ovarian Fibromata- 
Carcinoma-Sarcoma-Enchondroma-Tubercular Formations-Hydrocele of the 
Round Ligament-Peri-Uterine Haematocele-Pelvic Cellulitis-Gastro-Hyster- 6 
CONTENTS OF VOLUME II. 
PAGE 
otomy, or Caesarean Section-Operation-Porro Method-Laparo-Elytrotomy- 
Results-Diseases and Injuries of the Urethra and Bladder-Of the Urethra- 
Absence-Lacerations-Obliteration-Inflammation - Granular-Tumors -Poly- 
poid-Nervo-Vascular Urethrocele-Chronic Cystitis-Irritable Bladder-Extra- 
Uterine Pregnancy-Causes-Progress and Terminations-Diagnosis-Treatment 
-Removal of the Foetus per Vaginam-Placenta-Abdominal Section-Lapa- 
rotomy, or Gastrotomy-Rupture of the Sac-Rupture of the Uterus . . .716 
CHAPTER XXII. 
SURGICAL AFFECTIONS OF THE SPINAL OR DORSAL REGION-MALFORMATIONS OF 
THE HEAD FROM EFFUSION. 
Diseases of the Soft Parts over the Spine-Inflammatory Peculiarities-Wounds- 
Blood Tumors-Eruptions-Furuncles-Abscesses-Tumors-Sprains of Spine- 
Spinal Myalgia-Injuries of the Spinal Cord-Concussion-Wounds-Compres- 
sion-Injuries of the Spinal Column-Mechanism-Sprains-Contusions-Con- 
genital Defects of the Spine, and their Consequences-Hydrorachis-General 
Phenomena following Spinal Injuries-Diagnosis-Treatment-Curvatures of the 
Spine-Anatomical Peculiarities-Lateral-Symptoms-Structural Alterations- 
Treatment-Posterior-Anterior-Posterior Angular Curvature, or Pott's Disease 
- Causes - Structural Alterations - Spinal Abscesses - Diagnosis- Prognosis - 
Treatment by Mechanical Supports-Complications-Malformations of the Head 
from Effusion-Hydrocephalus Internus-Hydrocephalus Externus-Meningocele 
and Encephalocele 837 
CHAPTER XXIII. 
SURGICAL DISEASES OF THE MOUTH. 
Lips-Deformities-Contracted-Eversion and Depression-Chaps and Cracks- 
Ulcer-Hypertrophy-Hair-Moles -Wounds-Carbuncle-Tumors-Angeioma- 
tous Naevi-Cysts-Adenomata - Papillomata - Myxomata - Fibromata - Lipo- 
mata-Foreign Bodies in-Epitheliomata-Restoration-Hare-Lip-Single-Com- 
plications-Operation-After-Treatment-Double - Operation-Complications- 
Fissures of Lower Lip-Commissural Fissures, or Macrostoma-Injuries and Dis- 
eases of the Tongue-Congenital Absence-Adhesions-Tongue-Tie-Hypertrophy 
-Atrophy-Glossitis-Fissured Tongue-Papillary Disease-Wounds-Abscess- 
Ulcers-Strumous, or Tubercular-Tumors-Benign-Papillomata-Angeiomata 
- Cystomata-Lipomata-Fibromata - Enchondromata-Gummata- Malignant 
Neoplasms-Carcinomata-Treatment-Ablation of Tongue-Various Methods- 
Diseases of the Gum, Teeth, and Jaws-Hypertrophy of Gums-Tumid-Sloughing 
Ulcer-Tumors of Gums and Pulp-Cavities-Fibrous-Fibro-Angeiomata-Papil- 
loma-Epithelioma-Sarcoma-Epulis-Affections of the Teeth-Eruption, causing 
Inflammation-Irregularity-Dental Denudation and Abrasions-Dislocation - 
Fracture-Dental Caries-Necrosis-Alveolo-Dental Abscess, or Guin-Boil-Dif- 
ficult Eruption of the Wisdom-Teeth-Dental Fistula-Odontalgia-Treatment by 
Extraction - Instruments - Operation - Odontomes and Tooth Tumors - Hard 
Tumors-Enamel Nodules-Hypertrophy-Exostosis-Dentigerous Cysts-Solid 
Dentigerous Tumors, or Osteomata-Treatment-Cases of-Diseases and Injuries 
of the Jaws-Of the Lower Jaw-Deformities-Anchylosis-Periostitis-Osteitis 
-Abscess-Necrosis-Phosphor-Necrosis-Syphilitic-Mercurial-Tumors of the 
Lower Jaw-Cystic-Fibromata-Sarcomata-Enchondroma-Osteomata-Carci- 
noma-Affections of the Antrum and Upper Jaw-Inflammation of Antrum- 
Abscess-Antracele, or Dropsy of-Fistulous Opening into-Tumors-Tumors of 
the U pper J aw-Sarcoma-Carcinoma-Fibroma-Enchondroma-Osseous-Ex- 
cision of the Jaws-History-Of the Lower Jaw-Instruments-Partial-Middle 
of-Lateral Half of-Results-Of the Upper Jaw-Complete-Of Both-Partial - 
Results-Post-Maxillary Tumors-Cleft Palate-Staphylorraphy-History-Op- 
eration-After-Treatment-Affections of the Hard Palate-Hypertrophy-Abscess 
-Vascular Tumors-Gangrene-Cleft in the Hard Palate-Uranoplasty-Perfo- 
rations of Soft and Hard Palate-Affections of the Fauces-Elongation and Hyper- 
trophy of the Uvula-Affections of the Velum Palati-Inflammation-Wounds- 
Ulceration-Gummata-Abscess-Tumors-Cysts-Carcinoma-Fibroma-Affec- 
tions of the Tonsil-Foreign Bodies in-Hardened Secretions and Calculi-Para- CONTENTS OF VOLUME II. 
7 
sitic Cysts-Tonsillitis, or Quinsy-Hypertrophy-Excision-Atrophy-Ulceration 
-Abscess-Tumors of the Tonsil-Cystoma-Fibroma-Lymphoma-Carcinoma 
-Sarcoma-Diseases of the Salivary Glands-Of Sublingual-Cysts, or Ranula- 
Carcinoma - Of Submaxillary-Cysts - Enchondroma - Adeno-Sarcoma-Carci- 
noma-Calculi-Of Parotid-Inflammation, or Mumps-Abscess-Calculus-Fis- 
tula-Nervous Enlargement-Tumors-Accessory Gland-Tumors over the Parotid 
- Lymphoma-Fibrous - Affections of the Pharynx and (Esophagus - General 
Considerations-Congenital Defects-Neuroses of the Pharynx-Disorders of Sen- 
sation-Anaesthesia-Hyperaesthesia-Of Motion-Nervous Dysphagia-Chorea- 
Paralysis-Neuralgia-Inflammatory Affections of the Pharynx-Pharyngitis, 
Atrophic-Follicular-Diphtheritic-Syphilitic-Erysipelatous-Retropharyngeal 
Abscess-Scalds-Erosion by Caustics-Wounds-Fistula-Foreign Bodies in- 
Cicatricial Stenosis-Dilatation-Tumors-Affections of the (Esophagus-Congen- 
ital Imperfections - Foreign Bodies in-Wounds - Fistula - Retro-CEsophageal 
Abscess - Stenosis - Reflex - Organic - Pharyngo-CEsophageal and (Esophageal 
Pouches, or Diverticula-Varices-Morbid Growths of the (Esophagus-Fibro- 
mata, or Polypi-Sarcoma-Parasitic-Neuroses of the (Esophagus-Spasm-Par- 
alysis-(Esophagotomy-Operation-Results-Internal-Table of Cases-Poisons 
taken into the Stomach, and their Treatment-Mineral-Vegetable-Artificial In- 
troduction of Fluids into the Stomach, and the Use of the Stomach-Pump- 
Syringe-Evacuation of the Stomach-Operation ....... 889 LIST OF ILLUSTRATIONS TO VOLUME II. 
FIG. PAGE 
898. New socket formed for the head Of 
femur on the dorsum ilii. From 
preparation in the College of Phy- 
sicians 22 
899. Noose knot ..... 24 
900. Noose knot applied .... 24 
901. Clove-hitch 25 
902. Clove-hitch knot applied ... 25 
903. Indian basket for extension . . 25 
904. Indian basket for extension applied 25 
905. Gilbert's rope-windlass for extension 26 
906. Compound pulley .... 26 
907. Application of pulleys ... 26 
908. Staple screw for fastening counter- 
extension 27 
909. Separation of epiphysis of tibia, with 
compound dislocation ... 30 
910. Bilateral dislocation of lower jaw . 35 
911. Deformity in dislocation of lower jaw 35 
912. Unilateral dislocation of lower jaw . 36 
913. Reducing a dislocated lower jaw,- 
Smith ...... 37 
914. Dressing after reduction of a dislo- 
cated lower jaw,-Smith . . 37 
915. Forward dislocation between the 
fourth and fifth cervical vertebrae, 
-Smith ..... 42 
916. Side view of the above,-Smith . 42 
917. Ligaments connecting the clavicles to 
each other and to the sternum . 46 
918. Anterior dislocation of sternal end of 
clavicle,-Hamilton ... 47 
919. Deformity following the above . . 47 
920. Velpeau dressing for luxation at the 
sternal end of clavicle,-Smith . 47 
921. Dressing for posterior dislocation of 
clavicle,-Smith .... 48 
922. Dislocation of sternal end of clavicle 
upward,-Hamilton ... 49 
923. Dislocation of scapula beneath the 
clavicle,-Hamilton ... 50 
924. Deformity in downward dislocation 
of scapula 50 
925. Dressing for downward dislocation of 
scapula,-Smith .... 51 
926. Deformity in upward dislocation of 
scapula 52 
927. Dislocation of scapula above the 
clavicle ...... 52 
928. Subglenoid dislocation ... 54 
929. Subcoracoid dislocation ... 55 
930. Subclavicular dislocation ... 55 
931. Subspinous dislocation,-Hamilton . 55 
932. Deformity in dislocation of the shoul- 
der ...... 56 
933. Deformity in subcoracoid dislocation 57 
934. Deformity in subclavicular disloca- 
tion ...... 57 
FIG. PAGE 
935. Deformity in subspinous dislocation 57 
936. Showing reduction of the shoulder by 
manipulation .... 59 
937. Author's manipulation in reduction 
of shoulder ..... 60 
938. Reduction with the heel in the ax- 
illa,-Hamilton .... 60 
939. Reduction by La Mothe's method,- 
Hamilton ..... 61 
940. Reduction with scapula fixed by foot 62 
941. Reduction with arm at a right angle 
with the body .... 62 
942. N. Smith's method of reducing dislo- 
cated humerus .... 63 
943. Sir Astley Cooper's method of re- 
ducing dislocated humerus,-Ham- 
ilton 63 
944. Reduction of humerus by pulley ex- 
tension,-Hamilton ... 63 
945. Old unreduced luxation of the hu- 
merus, with fracture of the neck of 
the bone 66 
946. Displacement of the head of the hu- 
merus, with destruction of the 
tendon of the biceps muscle . . 67 
947. Anterior luxation of the head of the 
radius,-Hamilton ... 68 
948. Posterior luxation of the radius,- 
Hamilton 69 
949. Posterior luxation of the ulna,- 
Hamilton 70 
950. Relation of the bones and muscles in 
posterior luxation of the ulna,- 
Hamilton 71 
951. Deformity in posterior luxation of 
elbow ...... 71 
952. Reducing a dislocated elbow,-Ham- 
ilton ...... 72 
953. Anterior dislocation of the bones of 
the forearm,-Hamilton . . 74 
954. Outward dislocation of the forearm,- 
Hamilton 76 
955. Deformity in the above . . .76 
956. Inward dislocation of the forearm . 76 
957. Backward dislocation of the carpus . 79 
958. Deformity following the above,- 
Hamilton . . . . .79 
959. Deformity after anterior dislocation 
of the carpus,-Hamilton . . 79 
960. Anterior dislocation of the carpus,- 
Hamilton ..... 7 
961. Forward dislocation of the meta- 
carpus,-Erichsen ... 82 
962. Metacarpo-phalangeal dislocation of 
the thumb backward ... 83 
963. Deformity after the above . .83 
964. Dissection showing the relation of 
the metacarpal bone of the thumb 10 
LIST OF ILLUSTRATIONS TO VOLUME II. 
FIG. PAGE 
to the two portions of the short 
flexor, in posterior luxations of the 
thumb ...... 84 
965. Position of the phalanges in Crosby's 
method of reducing a dislocated 
thumb ...... 84 
966. Crosby's method of manipulation,- 
Smith 85 
967. Levis's lever-tractor . . .85 
968. Charriere's traction and lever forceps, 
-Gross 85 
969. Dislocation of the thumb forward . 86 
970. Anterior metacarpo-phalangeal dis- 
location 86 
971. Reduction of dislocated index finger, 
-Hamilton ..... 87 
972. Ilio-femoral or Y ligament . . 90 
973. Dislocation on the dorsum ilii . . 92 
974. Deformity from dislocation upon dor- 
sum ilii,-Hamilton ... 92 
975. Ischiatic dislocation,-Hamilton . 93 
976. Dislocation into ischiatic foramen,- 
Hamilton ..... 93 
977. Deformity after ischiatic dislocation, 
-Hamilton ..... 94 
978. Reduction of iliac and ischiatic dis- 
locations,-Smith .... 95 
979. Mechanism of reduction upon the 
principle of the windlass . . 95 
980. Reduction of an iliac dislocation by 
pulleys 97 
981. Reduction of an ischiatic dislocation 
by pulleys 97 
982. Relation of head of femur to the ilio- 
femoral ligament in obturator luxa- 
tions,-Hamilton .... 98 
983. Deformity after obturator disloca- 
tions ...... 98 
984. Reduction of an obturator dislocation 
by manipulation,-from Bigelow . 99 
985. Reduction of an obturator dislocation 
by pulleys,-after Sir Astley Cooper 100 
986. Position of head of femur in pubic 
dislocations 101 
987. Deformity after pubic dislocations . 101 
988. Reduction of pubic dislocations by 
extension and counter-extension, 
-Hamilton . . . . .101 
989. Normal position of patella . . 108 
990. Incomplete external dislocation of 
patella 108 
991. Complete external dislocation of pa- 
tella 108 
992. Incomplete inward dislocation of pa- 
tella ...... 109 
993. Completoinward dislocation of patella 109 
994. Vertical luxation of patella . . 109 
995. Anterior dislocation of the leg,- 
Hamilton 112 
996. Posterior dislocation of the tibia,- 
Hamilton ..... 112 
997. Incomplete internal luxation of bones 
of leg,-Hamilton. . . .113 
998. Incomplete external luxation of 
bones of leg,-Hamilton . . 113 
999. Relation of bones in an external rota- 
tory luxation of leg . . . 114 
1000. Deformity of external rotatory dislo- 
cation of leg 114 
1001. Dislocation of foot forward . .116 
1002. Dislocation of foot backward . . 117 
1003. Dislocation at ankle, with Pott's frac- 
ture 118 
1004. Deformity after above accident,- 
Hamilton 118 
1005. Dislocation of foot inward,-Ham- 
ilton 119 
FIG. PAGE 
1006. Dislocation of astragalus upward,- 
Gross 119 
1007. Compound dislocation of ankle,- 
Gross 120 
1008. Dislocation of the astragalus for- 
ward and outward, plantar aspect. 
From a cast taken by Dr. Hop- 
kins 122 
1009. The same, dorsal aspect . . .122 
1010. Compound dislocation of astragalus. 123 
1011. Subastragaloid luxation,-Holmes . 123 
1012. Fibrinous concretions in a joint . 128 
1013. Movable bodies in elbow-joint,-Cru- 
veilhier 128 
1014. Apparatus for straightening the knee, 
-Kolbe 144 
1015. Apparatus for anchylosis of elbow,- 
Kolbe ...... 144 
1016. Anteriorsplint, with Stromeyer screw, 
for anchylosed elbow . . . 144 
1017. Adams's knife ..... 145 
1018. Adams's subcutaneous osteotomy saw 145 
1019. Deformity from anchylosed knee, be- 
fore operation .... 146 
1020. Deformity of knee removed by oper- 
ation ...... 146 
1021. Fimbriated synovial membrane,- 
Pirrie, Gross ..... 148 
1022. Melon-seed-shaped bodies covering 
the synovial membrane of knee- 
joint,-Druitt, Gross . . . 148 
1023. Osseous deposits upon vertebrae after 
rheumatoid arthritis . . . 155 
1024. Dislocation and changes at shoulder- 
joint in rheumatoid arthritis. From 
a specimen at the College of Physi- 
cians, Philadelphia . . . 156 
1025. Microscopical appearance of articular 
arthritis,-after Weber . . 157 
1026. Deformity in the first stage of coxal- 
gia ...... 164 
1027. Arching of loins in coxalgia . .164 
1028. Elevation of pelvis in coxalgia . . 164 
1029. Deformity in the second stage of cox- 
algia ...... 165 
1030. Deformity in the third stage of cox- 
algia ...... 166 
1031. Pathological changes in incipient cox- 
algia ...... 168 
1032. Synovial membrane changed in cox- 
algia 169 
1033. Infiltration of ligamentum teres in 
coxalgia 169 
1034. Attachment of ligamentum teres to 
the acetabulum, with cartilage soft- 
ening, in coxalgia . . . . 169 
1035. Attachment of ligamentum teres to 
the femur in coxalgia . . . 169 
1036. Changes in head and neck of femur 
in coxalgia,-Author's collection . 170 
1037. Perforation of acetabulum, with ca- 
rious femur, in coxalgia . . 170 
1038. Head of femur flattened and anchy- 
losed in coxalgia,-Smith . . 170 
1039. New socket for femur between the 
spines of ilium,-Smith . . 171 
1040. New socket for femur on dorsum ilii, 
-Smith 171 
1041. New socket on dorsum ilii for dwarfed 
head of femur,-Smith . . . 171 
1042. Limb anchylosed at nearly a right 
angle to pelvis in coxalgia . .174 
1043. Limb anchylosed in adduction in 
coxalgia 174 
1044. Hip-joint splint .... 176 
1045. Wrench for bending steel splints . 176 
1046. Hip-joint splint in position . . 177 LIST OF ILLUSTRATIONS TO VOLUME II. 
11 
no. PAGE 
1047. Hip-joint splint applied . . . 177 
1048. Hip-joint splint prepared for buckling 
to the limb 177 
1049. Gradual extension in coxalgia . . 178 
1050. Author's splint in after-treatment of • 
coxalgia 179 
1051. Davis's splint in coxalgia . . 179 
1052. Adhesive plaster applied for Davis's 
splint,-Smith .... 180 
1053. Davis's splint applied, side view . 181 
1054. Davis's splint applied, front view . 181 
1055. Sayre's hip-joint splint . . . 181 
1056. Fan-shaped adhesive plaster used 
with Sayre's splint,-from Sayre . 182 
1057. Fan-shaped plaster in position,- 
from Sayre 182 
1058. Fan-shaped plaster fastened with a 
roller,-from Sayre . . . 182 
1059. Sayre's modification of Taylor's 
splint 183 
1060. Knee-joint disease, with displace- 
ment 187 
1061. Sayre's apparatus for knee-joint dis- 
ease 188 
1062. Adhesive plaster applied as used 
with Sayre's knee apparatus,- 
after Sayre ..... 188 
1063. Sayre's knee apparatus applied . 189 
1064. Thomas's knee-joint splint . .189 
1065. Appearance of ankle-joint disease . 190 
1066. Gouge and scraper .... 192 
1067. Burr 192 
1068. Sayre's splint for ankle-disease . 193 
1069. Sayre's splint for ankle-disease ap- 
plied 193 
1070. Appearance of strumous disease of 
elbow-joint 201 
1071. Appearance of arthritis of wrist . 203 
1072. Periosteal elevator .... 209 
1073. Retractors ..... 209 
1074. Bone director 209 
1075. Narrow periosteal elevator . . 210 
1076. Butcher's saw 210 
1077. Chain-saw 210 
1078. Metacarpal saws .... 210 
1079. Semicircular saw .... 210 
1080. Lion forceps 211 
1081. Curved pliers ..... 211 
1082. Straight cutting pliers . . .211 
1083. Curved cutting pliers . . .211 
1084. Gouge 211 
1085. Excision of shoulder-joint . .214 
1086. Appearance of bones after excision of 
elbow-joint 217 
1087. Plaster-splint after excision of elbow 218 
1088. Lister's incisions for excision of 
wrist 221 
1089. Structures involved in Lister's excis- 
ion of wrist,-from Lister . . 222 
1090. Splint applied after excision of wrist 222 
1091. Incision for excision of hip . . 229 
1092. Head of femur displaced prior to re- 
moval ..... 229 
1093. Section of femur at base of trochan- 
termajor 230 
1094. Wire breeches, or cuirass . . . 230 
1095. Anterior semicircular flap in excision 
of knee-joint .... 234 
1096. Showing method of excising the 
knee-joint 235 
1097. Showing the extent of bone to be 
removed in excisions of knee . 235 
1098. Plaster splint suspended in excision 
of knee 236 
1099. Ashhurst's wire splint . . . 236 
1100. Price's bracketed splint . . . 237 
1101. Incisions for excision of ankle-joint 241 
FIG. PAGE 
1102. Appearance of foot after excision of 
ankle-joint 242 
1103. Incisions for exposing the scapula . 249 
1104. Apparatus worn after excision of 
fibula ...... 255 
1105. Os calcis exposed by plantar flap,- 
Gross 258 
1106. First position of knife . . . 261 
1107. Second position of knife . . . 261 
1108. Third position of knife . . . 261 
1109. Fourth position of knife . . . 262 
1110. Fifth position of knife . . . 262 
1111. Sixth position of knife . . . 262 
1112. Mode of fixing the skin while in- 
cising 263 
1113. Linear, or straight incision . . 264 
1114. Curvilinear, or italic letter £ incision . 264 
1115. Elliptical incision .... 264 
1116. Semilunar incision .... 264 
1117. Incision of ellipse .... 264 
1118. Acupuncture needle and handle . 264 
1119. Multipuncture instrument . . 265 
1120. Arrangement of veins at bend of arm 265 
1121. Thumb lancet 266 
1122. Spring lancet 266 
1123. Morton's hospital wagon . . .276 
1124. Allis's inhaler 285 
1125. Cone for inhalation formed out of a 
towel ...... 285 
1126. Thomas's nitrous oxide inhaler . . 289 
Tracings of normal pulse, and when 
fully under ether .... 290 
Tracings of normal pulse, and when 
fully under chloroform . . . 291 
1127. Hand atomizer ..... 292 
1128. Position of knife in beginning a cir- 
cular amputation .... 301 
1129. Circular flaps dissected and reflected 301 
1130. Appearance of stump after a circular 
amputation 302 
1131. Formation of oval tegumentary flaps 303 
1132. Appearance of the wound after the 
bi-musculo-tegumentary flaps . 305 
1133. Author's modification of flap ampu- 
tations 305 
1134. Formation of semi-musculo-tegumen- 
tary flaps 306 
1135. Lines of incision in Teale's rectangu- 
lar amputation,-Smith . . 306 
1136. Appearance of flaps when adjusted 
after Teale's operation,-Smith . 307 
1137. Tourniquet of Petit .... 309 
1138. Amputating knives .... 310 
1139. Long and short catling . . . 310 
1140. Catling and amputating knife com- 
bined 310 
1141. Amputating saw, with narrow blade . 310 
1142. Amputating saw, with broad blade . 310 
1143. Small-sized amputating saws . .311 
1144. Bone pliers 311 
1145. Scalpel 311 
1146. Amputating case .... 311 
1147. Position of assistants during ampu- 
tation 312 
1148. Appearance of a stump after ampu- 
tation 314 
1149. Segmented cradle for stump . . 316 
1150. Cradle suspended, with one segment 
lowered ...... 316 
1151. Stump secured to a pillow . . 317 
1152. Structure of stump one year after 
healing 317 
1153. Extension applied to scanty flaps of 
a stump 320 
1154. Conical stumps 321 
1155. Bulbous enlargement of nerves of a 
stump,-Holmes .... 321 12 
LIST OF ILLUSTRATIONS TO VOLUME IL 
FIG. PAGE 
1156. Peg leg 328 
1157. Modern artificial leg . . . . 328 
1158. Artificial mechanism for the forearm 328 
1159. Neill's knife for amputating fingers . 334 
1160. Anatomical relation of phalangesand 
metacarpal bones .... 334 
1161. Mode of amputating a finger . . 334 
1162. Forming an anterior flap in ampu- 
tating a finger .... 335 
1163. Incision for metacarpo-phalangeal 
amputation ..... 335 
1164. Knife passing through the metacarpo- 
phalangeal joint .... 335 
1165. Appearance of wound after meta- 
carpo-phalangeal amputation . 335 
1166. Appearance of hand after amputa- 
tion of the little finger . . . 336 
1167. Incision for removing the thumb with 
its metacarpal bone . . . 337 
1168. Dividing deep attachments of the 
metacarpal bone of thumb . . 337 
1169. Hand after amputation of the thumb 
and its metacarpal bone . . . 338 
1170. Method of amputating the metacar- 
pal bones of the four fingers . . 338 
1171. Radio-carpal articulation . • . 340 
1172. Incision for amputating at the wrist. 340 
1173. Knife carried through wrist-joint 
prior to cutting the palmar flap . 340 
1174. Artificial arm and hand . . . 340 
1175. Artificial hand detached . . • 340 
1176. Nipper applied to artificial arm . 340 
1177. Musculo-tegumentary flap amputa- 
tion at the middle of forearm . 341 
1178. Amputation at the upper third of 
forearm . . . . . . 342 
1179. Section showing the components of a 
stump of forearm .... 342 
1180. Anterior musculo-tegumentary flap 
formed in elbow amputations . . 343 
1181. Musculo-tegumentary method of am- 
putating the arm .... 344 
1182. Appearance of stump of arm after 
above method .... 344 
1183. Relations of structures after amputa- 
tion through the middle of arm . 345 
1184. Stump of arm after musculo-tegumen- 
tary amputation .... 345 
1185. Teale's amputation at lower third of 
humerus ..... 345 
1186. Flaps after Teale's amputation of 
arm 346 
1187. Artificial arm for use above elbow . 346 
1188. Larrey's shoulder-joint amputation . 346 
1189. Control of axillary artery in shoulder- 
joint amputations .... 347 
1190; Stump after Larrey's amputation . 347 
1191. Stump after Dupuytren's amputation 
at the shoulder-joint . . . 348 
1192. Lisfranc's shoulder-joint amputation, 
-Gross ...... 348 
1193. Spence's shoulder-joint amputation, 
-Erichsen ..... 349 
1194. Artificial limb applied after shoulder- 
joint amputation .... 350 
1195. Incisions for metatarso-phalangeal 
amputations ..... 352 
1196. Stump after amputation of all the 
toes at metatarso-phalangeal joints 353 
1197. Bones of the foot .... 353 
1198. Lines showing the various amputa- 
tions through the articulations of 
the foot 354 
1199. Surface-markings for amputations 
through the foot .... 354 
1200. Separating the second metatarsal bone 
in Lisfranc's amputation of foot . 355 
FIG. PAGE 
1201. Forming plantar flap in Lisfranc's 
amputation 356 
1202. Appearance of wound in Lisfranc's 
amputation of foot,-Gross . . 356 
1203. Stump after Lisfranc's amputation of 
foot ...... 356 
1204. Forming flaps in Chopart's amputa- 
tion of foot 357 
1205. Stump after Chopart's amputation . 357 
1206. Removal of os calcis in Syme's ampu- 
tation,-Gross .... 359 
1207. Stump after Syme's amputation,- 
Gross 359 
1208. Sawing the os calcis in Pirogoff's am- 
putation 360 
1209. Lines of separation in amputations 
at the ankle 360 
1210. Osseous union of calcaneum with 
bones of the leg in author's ankle 
amputation 361 
1211. Stump after Pirogoff's amputation . 361 
1212. Lines of incision for amputations 
upon the lower extremity . 362 
1213. Antero-posterior oval tegumentary 
amputation at lower third of leg . 362 
1214. Teale's amputation at lower third of 
leg....... 363 
1215. Flaps of Teale's amputation adjusted 363 
1216. Amputation of leg at its upper third 364 
1217. Relation of structures in a stump of 
leg....... 364 
1218. Stump after amputation at upper 
third of leg ..... 365 
1219. Peg leg 365 
1220. Modern artificial leg .... 365 
1221. Anterior flap formed in knee-joint 
amputations 366 
1222. Condyloid amputation of knee . . 368 
1223. Carden's amputation of knee,-from 
Bryant ...... 368 
1224. Lines of incision for various knee- 
joint amputations .... 369 
1225. Relation of structures of stump of 
thigh . . . . . .370 
1226. Anterior flap by transfixion in ampu- 
tations of thigh .... 370 
1227. Method of sawing the bone iji thigh 
amputations ..... 370 
1228. Artificial limb for the thigh . . 371 
1229. Exposure of the mechanism of the 
same . 371 
1230. Abdominal tourniquet applied . . 372 
1231. Forming the anterior flap in hip-joint 
amputations 374 
1232. Pulse-tracings during shock . . 376 
1233. Fever-chart in complicated infective 
fever ...... 392 
1234. Fever-chart in pyaemia . . . 393 
1235. Crucial incision of carbuncle . . 401 
1236. Deformity alter burns of face and 
neck ...... 416 
1237. Cicatricial contraction of chin after 
burns 416 
1238. Arm flexed and bound by cicatrix 
after burns 416 
1239. Plastic operation for cicatricial con- 
tractions of elbow .... 420 
1240. Phimosis ...... 426 
1241. Phimosis forceps .... 427 
1242. Operation of circumcision . . 428 
1243. Mucous membrane stitched to skin 
after circumcision .... 428 
1244. Incision in phimosis . . . 429 
1245. Levis's forceps in phimosis . . 429 
1246. Paraphimosis ..... 430 
1247. Phillips's method of reducing para- 
phimosis 431 LIST OF ILLUSTRATIONS TO VOLUME II. 
13 
FIG. PAGE 
1248. Author's method of reducing para- 
phimosis ..... 431 
1249. Dividing the stricture in paraphi- 
mosis 431 
1250. Epithelioma of prepuce . . . 432 
1251. Clamp forceps for compressing the 
penis 433 
1252. Urinal for use after amputation of 
the penis 434 
1253. Warts on the penis .... 438 
1254. Urethral fistulie opening in the peri- 
neum ....*. 446 
1255. Fistula in penile urethra closed by 
quilled suture .... 448 
1256. Urethroplasty 449 
1257. Nelaton's method of urethroplasty . 449 
1258. Articulated scoop of Leroy d'Etiolles. 455 
1259. Manner of extracting foreign bodies 
from the urethra .... 455 
1260. Matthews's urethral forceps . . 455 
1261. Gross's urethral forceps . . . 455 
1262. Foreign body in urethra grasped by 
forceps 456 
1263. Hunter's or Civiale's urethral for- 
ceps 456 
1264. Reliquet's urethral lithotrite . . 456 
1265. Luar's urethral forceps . . . 458 
1266. Hard rubber urethral syringe,-Smith 464 
1267. Manner of injecting the urethra . 465 
1268. Syringe for deep urethral injections . 472 
1269. Instrument for local cauterization of 
the urethra 473 
1270. Instrument for cauterizing limited 
districts of the urethra . . 473 
1271. Membranous stricture of the urethra 478 
1272. Indurated stricture of the urethra . 478 
1273. Metallic bulbous bougie . . . 480 
1274. Soft bulbous bougie of Leroy d'Eti- 
olles 480 
1275. Interior of bladder after urethral 
stricture 481 
1276. Urethra-metre of Otis . .' . 483 
1277. Conical soft bougie .... 483 
1278. Olive-shaped bougie .... 483 
1279. English catheter scale . . . 484 
1280. French catheter scale . . . 484 
1281. Thomas's adaptable metric urethral 
gauge ...... 485 
1282. Thomas's gauge applied . . . 485 
1283. Filiform whalebone bougies . . 486 
1284. Hollow bougie passed over a filiform 
guide 486 
1285. Wakely instruments for dilating ure- 
thral strictures .... 487 
1286. Holt's divulsor 488 
1287. Billings's divulsor .... 488 
1288. Thompson's dilator .... 490 
1289. Rigaud's dilator .... 490 
1290. Gross's urethrotome .... 491 
1291. Otis's dilating urethrotome , . 491 
1292. Mastin's dilating urethrotome • . 492 
1293. Syme's staff 493 
1294. Gouley's catheter staff . . . 493 
1295. Catheter for applying nitrate of silver 
to the prostatic sinuses . . 497 
1296. General enlargement of the prostate. 
From a preparation in the College 
of Physicians, Philadelphia . . 500 
1297. Multiple tumors of prostate project- 
ing into bladder .... 501 
1298. Soft Mercier catheter . . . 504 
1299. Soft catheter with stylet . . . 504 
1300. Silver catheter curved to suit an en- 
larged prostate .... 504 
1301. Prostatic calculus .... 505 
1302. Author's blood catheter . . . 508 
1303. Squire's vertebrated catheter . . 510 
FIG. PAGE 
1304. Gross's spiral catheter . . .510 
1305. Trocar for tapping the bladder . 513 
1306. Positions of tapping the bladder 
shown 514 
1307. Varix of the scrotum . . . 517 
1308. Section of cystic scrotal tumor,-from 
Curling 520 
1309. Neill's case of elephantiasis of scro- 
tum and penis, before operation,- 
American Journal of the Medical 
Sciences 521 
1310. Neill's case after operation . . 521 
1311. Microscopic appearance of skin in 
elephantiasis' of scrotum,-Ameri- 
can Journal of the Medical Sci- 
ences 522 
1312. Titley's case of elephantiasis of scro- 
tum,-Gross 523 
1313. Lymph scrotum,-from Carter . . 525 
1314. Epithelial cancer of the scrotum . 525 
1315. Gum bag for injecting the bladder . 531 
1316. Gravity apparatus for washing the 
bladder ...... 531 
1317. Harrison's suppository carrier for the 
bladder 531 
1318. Multiple papilloma of the bladder . 547 
1319. Dilator for female urethra . . 549 
1320. Forceps for removing fibroma from 
the female bladder . . . 550 
1321. Normal course of male urethra . 551 
1322. Metallic catheter .... 551 
1323. Soft catheter with stylet . . . 552 
1324. Soft catheter, showing its flexibility . 552 
1325. Olive-shaped gum catheter . . 552 
1326. Introduction of the catheter upon 
the male ..... 553 
1327. Catheter retained by adhesive plaster 554 
1328. Holt's winged catheter . . . 554 
1329. Female catheter .... 555 
1330. Position of female catheter for intro- 
duction ...... 556 
1331. Diffused hydrocele of the cord . . 559 
1332. Encysted hydrocele of the cord . 560 
1333. Bowman's case of hmmatocele . . 562 
1334. Veins in varicocele .... 563 
1335. Morgan's suspensory for varicocele 
applied,-Bryant . . . *. 565 
1336. Adhesive plaster suspensory for vari- 
cocele applied .... 565 
1337. Pad of truss for varicocele . . . 565 
1338. Scrotum opened to show the subcuta- 
neous ligation of the spermatic 
veins ...... 566 
1339. Trocar for hydrocele . . . . 573 
1340. Manner of tapping a hydrocele . 574 
1341. Thickening of tunics of testis pro- 
duced by an old hydrocele . . 580 
1342. Sling for the testicle . . . . 583 
1343. Adhesive strips applied to the tes- 
ticle 583 
1344. Section of testicle showing fibrous de- 
generation, also spaces filled with 
caseous matter .... 586 
1345. Fungus, or " hernia testis" . . 589 
1346. Fungous granulations from the tunica 
albuginea testis .... 589 
1347. Encephaloid fungus of testicle . . 590 
1348. Microscopic view of sarcoma of tes- 
ticle ...... 592 
1349. Cystic disease of testicle. From 
preparation at University of Penn- 
sylvania 593 
1350. Mode of securing the vessels of cord 
in castration 599 
1351. Lallemand's urethral porte-caustic . 608 
1352. Urinal for exstrophy of bladder ap- 
plied 613 14 
LIST OF ILLUSTRATIONS TO VOLUME II. 
FIG. PAGE 
1353. Lines of incision in Wood's method 
for exstrophy of bladder,-from 
Ashhurst ..... 614 
1354. Maury's operation for exstrophy of 
bladder 614 
1355. Clinical urinometer .... 617 
1356. Mode of using the urinometer . • 617 
1357. Microscopic appearance of pus in the 
urine,-Da Costa . . . .619 
1358. Microscopic appearance of epithe- 
lium in the urine,-Da Costa . . 620 
1359. Tube-casts in acute desquamative ne- 
phritis in the urine,-Da Costa . 621 
1360. Granular tube-casts,-Da Costa . 621 
1361. Fatty tube-casts,-Da Costa . . 621 
1362. Hyaline waxy casts, with epithelial 
cells from the bladder,-Da Costa . 621 
1363. Spermatozoa ..... 622 
1364. Uric acid crystals,-Da Costa . . 624 
1365. Amorphous urates,-Da Costa . . 624 
1366. Crystals of oxalate of lime . . 626 
1367. Crystals of triple phosphates . . 628 
1368. Calculus covered with sharp spines . 634 
1369. Nucleus lying loose in an oxalate of 
lime calculus ..... 635 
1370. Inner and outer appearance of a uric 
acid calculus..... 636 
1371. Interior of uric acid calculus . . 636 
1372. Surface of an oxalate of lime calculus 637 
1373. Cystine calculus,-Gross . . . 638 
1374. Ammoniaco-magnesian phosphatic 
calculus,-Gross .... 639 
1375. Mixed or fusible calculus,-Gross . 639 
1376. Curves necessary for sounds . . 642 
1377. Sound with sounding-board of L'Es- 
trange attached .... 643 
1378. Sounding for stone in the post-pros- 
tate pouch of bladder . . . 644 
1379. Sacculated stone .... 644 
1380. Stone lodged against the anterior wall 
of bladder 645 
1381. Thompson's sound for measuring 
stone in the bladder . . . . 647 
1382. Catheter for removing calculi • . 650 
1383. Sir Astley Cooper's forceps for seizing 
vesical calculi .... 650 
1384. Fergusson's lithotrite . . . 652 
1385. Civiale and Charriere's lithotrite . 652 
1386. Sir Henry Thompson's lithotrite . 652 
1387. Fenestrated lithotrite . . • 653 
1388. Flat-bladed lithotrite . . . 653 
1389. Wedge-shaped lithotrite blades . 653 
1390. Manner of holding the lithotrite 
when separating its blades . . 655 
1391. Stone raised before crushing . . 655 
1392. Bigelow's lithotrite .... 658 
1393. Clover's evacuating apparatus . . 658 
1394. Bigelow's evacuating apparatus . 659 
1395. Dissection of male perineum • . 667 
1396. Lithotomy staff .... 668 
1397. Author's lithotomy knife . . . 668 
1398. Blunt-pointed bistoury . • . 668 
1399. Various kinds of lithotomy knives . 668 
1400. Lithotomy forceps .... 669 
1401. Lithotomy scoop .... 669 
1402. Catheter for injecting the bladder . 669 
1403. Catheter with Davidson's syringe at- 
tached 669 
1404. Catheter sound. . . . . 670 
1405. Large forceps for breaking stone . 670 
1406. Position of patient and assistants 
during lithotomy .... 671 
1407. Mode of directing the knife into the 
groove of the staff .... 671 
1408. Position of forceps prior to grasping 
the stone ..... 672 
1409. Physick's gorget .... 672 
FIG. PAGE 
1410. N. R. Smith's lithotomy instrument. 673 
1411. Stone in the inferior fundus of blad- 
der ....... 675 
1412. Physick's forceps and needle . . 677 
1413. Horner's awl 677 
1414. Chemise for hemorrhage . . . 678 
1415. Buckstone's tampon for hemorrhage, 
-Sir H. Thompson . . . 678 
1416. Little's director .... 687 
1417. Buchanan's staff .... 687 
1418. Incision of perineum and prostate on 
the rectangular staff . • . 688 
1419. Incision in bilateral lithotomy,- 
Gross 688 
1420. Double lithotome cache . . . 689 
1421. Diagram showing the three primary 
incisions for lithotomy . . . 689 
1422. Supra-pubic lithotomy . . . 691 
1423. Dilator for female urethra . . 694 
1424. Staff for female urethral lithotomy . 695 
1425. Pouches of sacculated kidney con- 
taining calculi .... 701 
1426. Follicular disease of vulva,- 
Thomas ...... 719 
1427. Hypertrophied labia. . . . 720 
1428. Varicose veins of labium . . . 720 
1429. Papilloma of labium,-Emmett . 721 
1430. Epithelioma of labium . . . 722 
1431. Cyst of labium ..... 723 
1432. Hypertrophy of the clitoris . . 723 
1433. Scalpel for lacerated perineum . . 729 
1434. Forceps for lacerated perineum . 729 
1435. Scissors for lacerated perineum . 729 
1436. Needle for lacerated perineum . . 729 
1437. Shot-compressor for lacerated peri- 
neum ...... 729 
1438. Denuded surfaces of lacerated peri- 
neum 730 
1439. Sutures for lacerated perineum in 
position 731 
1440. Lacerated perineum closed . . 731 
1441. Utero-vaginal prolapse, w'ith cysto- 
cele and rectocele .... 736 
1442. Sims duck-bill speculum . . . 744 
1443. Author's forceps for vesico-vaginal 
fistula 744 
1444. Knives for vesico-vaginal fistula . 744 
1445. Needle-holder ..... 744 
1446. Self-retaining catheter . . .744 
1447. Needles for vesico-vaginal fistula . 744 
1448. Scissors for vesico-vaginal fistula . 745 
1449. Shot-perforator 745 
1450. Position, with speculum in place, for 
vesico-vaginal fistula . . .745 
1451. Manner of passing the sutures in 
vesico-vaginal fistula . . .746 
1452. Sutures in position in vesico-vaginal 
fistula 746 
1453. Shot-compressor .... 747 
1454. Appearance of vesico-vaginal fistula 
when closed 747 
1455. Suture after removal from vesico-va- 
ginal fistula 748 
1456. Destruction of vesico-vaginal septum 
almost complete .... 748 
1457. Manner of closing the vagina . . 749 
1458. Simultaneous abdominal and vaginal 
examination . . . . .751 
1459. Bivalve vaginal speculum . . 751 
1460. Cylinder speculum for vagina . . 751 
1461. Uterine sounds or probes . . . 752 
1462. Uterine tenaculum .... 752 
1463. Claw-toothed forceps . . .752 
1464. Sponge-holder 753 
1465. Complete procidentia uteri,-Thomas 753 
1466. Meigs's ring pessary • . . 754 
1467. Hodge's lever pessary . . .754 LIST OF ILLUSTRATIONS TO VOLUME II. 
15 
FIG. PAGE 
1468. Adjusting the lever pessary . . 754 
1469. Cup pessary . . . • .755 
1470. Operation for prolapsus uteri . . 755 
1471. Slight retroversion of the uterus . 756 
1472. Sims's uterine elevator, or repositor . 756 
1473. Repositor introduced prior to re- 
placing the uterus,-Thomas . 757 
1474. Uterus raised into position by reposi- 
tor,-Thomas . . . .757 
1475. Genu-pectoral position . . . 758 
1476. Anteversion of the uterus . . 759 
1477. Thomas's anteversion pessary . . 759 
1478. Anteflexion of the uterus . . . 760 
1479. Retroflexion of the uterus . .760 
1480. Campbell's soft rubber spring stem 
pessary 761 
1481. Scissors for dividing the cervix uteri 762 
1482. Uterotome 762 
1483. Manner of closing a lacerated cervix 
uteri 763 
1484. Dilators for cervix uteri . . . 766 
1485. Intramural fibroma of uterus . . 767 
1486. Subperitoneal fibroma of uterus . 767 
1487. Submucous fibroma of uterus . . 767 
1488. Sponge tent 770 
1489. Sponge-tent forceps .... 770 
1490. Sponge-tent director . . . 770 
1491. Thomas's spoon-saw .... 771 
1492. Ecraseur 771 
1493. Wire Ecraseur 771 
1494. Fork for placing the chain of an ecra- 
seur around a fibroid . . . 772 
1495. Mucous polypus pedunculated to 
cervix uteri 774 
1496. Uterine polypus forceps . . . 775 
1497. Author's ecraseur .... 775 
1498. Hodge's polypotome .... 775 
1499. Uterine curette .... 775 
1500. Vulsellum tenaculum . . . 776 
1501. Gooch's canula 777 
1502. Manner of extirpating the uterus . 781 
1503. Endogenous multilocular ovarian 
cyst,-Atlee 794 
1504. Interior of a multilocular cyst,- 
Atlee 794 
1505. Multilocular cyst, loculi distinct,- 
Atlee 794 
1596. Fibre or spindle cells, also epithelial 
cells, found in fibro-cystic tumors 
of Uterus,-Atlee .... 796 
1507. Cyst of broad ligament mistaken for 
ovarian tumor,-Atlee . . . 796 
1508. Microscopic forms in ovarian fluids, 
-Atlee 797 
1509. Trocar for tapping ovarian cysts . 800 
1510. Trocar for ovarian cysts after being 
exposed 804 
1511. Wells's ovarian trocar . . . 805 
1512. Needle for sewing the abdominal 
walls 805 
1513. Atlee's clamp, open and closed . . 805 
1514. Wells's clamp ..... 806 
1515. Spray apparatus .... 806 
1516. Dermoid ovarian cyst, containing 
hair, fat, and a tooth. From speci- 
men at University of Pennsylvania 813 
1517. Haematocele in Douglas's cul-de-sac 815 
1518. Subperitoneal haematocele . .815 
1519. Lipoma of back .... 838 
1520. Perforation of cervical vertebrae and 
of the cord 845 
1521. Clot of blood in spinal canal . . 845 
1522. Hydrorachis from lumbo-saeral re- 
gion 851 
1523. Normal curves of spine . . . 859 
1524. Primary and secondary lateral cur- 
vatures of spine .... 860 
FIG. PAGE 
1525. Deformity in lateral curvature of 
spine 863 
1526. Structural alterations induced by lat- 
eral curvature of spine . . . 864 
1527. Kolbe's apparatus for lateral curva- 
ture 865 
1528. Davis's apparatus for lateral curva- 
ture 865 
1529. Kolbe's spinal jacket . • . 866 
1530. Deformity in extreme posterior cur- 
vature of spine .... 866 
1531. Deformity in anterior curvature of 
spine 868 
1532. Vertebrae excavated by caries in 
Pott's disease of spine . . . 871 
1533. Psoas abscess in Pott's disease . . 872 
1534. Standing position in Pott's disease . 873 
1535. Manner of picking up objects in 
Pott's disease .... 873 
1536. Deformity in Pott's disease . . 874 
1537. Spinal jacket with head-support . 878 
1538. The above jacket applied . . . 878 
1539. Suspension apparatus for Pott's dis- 
ease ...... 879 
1540. Child suspended in Pott's disease . 879 
1541. Apparatus for support to head . . 880 
1542. Plaster jacket applied . . . 880 
1543. Leather spinal jacket with head- 
piece ...... 881 
1544. The above applied .... 881 
1545. Johnson's felt jacket for Pott's dis- 
ease applied ..... 881 
1546. Apparatus for coxalgia with Pott's 
disease 884 
1547. Separation of cranial bones in hydro- 
cephalus ..... 885 
1548. Deformity in hydrocephalus • . 885 
1549. Meningocele ..... 887 
1550. Absence of parietal bone in menin- 
gocele 887 
1551. Appearance of meningocele after re- 
moval by elastic ligature . . 888 
1552. Contracted mouth .... 889 
1553. Operation for contracted mouth . 889 
1554. Double lip ..... 891 
1555. Epithelioma of lip . . . . 894 
1556. Removal of epithelioma of lip . . 895 
1557. Buchanan's operation for new lower 
lip 896 
1558. The above with flaps adjusted . . 896 
1559. Dieffenbach's operation for upper lip . 896 
1560. The above with flaps adjusted . . 896 
1561. Sedillot's operation for upper lip,- 
Ashhurst 897 
1562. Reversed V incision for hare-lip . 899 
1563. Semi-elliptical incision for hare-lip . 899 
1564. Triangular incision for hare-lip . 899 
1565. Reversed triangular incision for hare- 
lip 899 
1566. Closure of hare-lip .... 900 
1567. Appearance of lip after Collis's oper- 
ation,-Garretson .... 901 
1568. Incisions for double hare-lip . . 901 
1569. Anterior projection of intermaxillary 
bone , 902 
1570. Gap between the superior maxillary 
bones,-Erichsen .... 902 
1571. Hainsby's truss forpressure on upper 
jaws 902 
1572. Cutting the fraenum in tongue-tie . 905 
1573. Use of director in division of fraenum 905 
1574. Hypertrophy of the tongue . . 905 
15-75. Hypertrophied epithelial cells in hy- 
pertrophy of tongue . . . 905 
1576. O'idium albicans .... 910 
1577. Lingual cyst ..... 911 
1578. Gag for separating the jaws . . 914 16 
LIST OF ILLUSTRATIONS TO VOLUME II. 
FIG. PAGE 
1579. Museux forceps .... 914 
1580. Ligating cancer of the tongue . . 915 
1581. Strangulating cancer of tongue by 
double thread,-Eriehsen . .915 
1582. Chain and probe passed through the 
tongue along a bistoury , . 916 
1583. Removal of one-half of tongue by 
two 6craseurs; gag introduced . 916 
1584. Removal of tongue through the sym- 
physis of jaw .... 917 
1585. Incision in Regnoli's removal of 
tongue ...... 917 
1586. Tongue drawn out in Regnoli's oper- 
ation,-Erichsen .... 917 
1587. Nunneley's method of removing the 
tongue ...... 918 
1588. Jordan's method of removing the 
tongue . • . . . .918 
1589. Hypertrophy of the gums,-Heath . 919 
1590. Dentist's scaler . .... 920 
1591. Fibrous tumor of gums,-Garretson. 921 
1592. Fungoid growths from the dental 
pulp ...... 922 
1593. Erectile tumor of gum of upper jaw, 
-Garretson . . . . . 922 
1594. Epulis of upper jaw,-Erichsen . 923 
1595. Gum lancet ..... 924 
1596. Vicious position of central incisors, 
-Garretson ..... 925 
1597. Correcting misplaced incisor by elas- 
tic bands,-Garretson . . . 925 
1598. Correcting misplaced incisor by silk 
cords,-Garretson . . . . 925 
1599. Caries of a tooth,-Garretson . . 927 
1600. Alveolar abscess at root of tooth . 928 
1601. Forceps for upper incisors . . 932 
1602. Forceps for upper incisors . . 932 
1603. Forceps for lower incisors . . . 932 
1604. Forceps for lower incisors . . . 932 
1605. Forceps for upper bicuspids or ca- 
nines ...... 932 
1606. Forceps for bicuspids of either jaw . 933 
1607. Forceps for lower bicuspids . . 933 
1608. Forceps for molars .... 933 
1609. Forceps for molars .... 933 
1610. Spray apparatus for freezing gums . 934 
1611. Narrow-bladed forceps for roots • 935 
1612. Screws for extracting roots . . 935 
1613. Cutting and elevating pliers . . 936 
1614. Fusion of roots of teeth . • . 936 
1615. Enamel nodule,-Forget . . . 937 
1616. Hypertrophy of tooth, with enamel 
nodule,-Garretson . . . 937 
1617. Microscopic appearance of hypertro- 
phied tooth,-Garretson . . 937 
1618. Bony tumor attached to molar tooth 937 
1619. Section of same,-Forget . . . 937 
1620. Tumor from dental pulp,-specimen 
in University of Pennsylvania . 938 
1621. Molars entangled .... 938 
1622. Cyst of jaw from misplaced tooth, 
laid open ..... 938 
1623. Multilocular cystoma from a mis- 
placed tooth ..... 940 
1624. Dentigerous osteoma . . . 940 
1625. Section of same .... 941 
1626. Localized dentigerous osteoma, re- 
moved by operation,-Garretson . 941 
1627. Microscopic section showing the cha- 
otic disposition of dental structures, 
-Garretson ..... 942 
1628. Divulsors or lever forceps for jaws . 948 
1629. Circumscribed abscess of lower jaw, 
-Gross 950 
1630. Phosphor-necrosed lower jaw,-Sur- 
gery Pennsylvania Hospital . . 952 
FIG. PAGE 
1631. Sarcoma of lower jaw . . . 956 
1632. Cystic sarcoma of lower jaw . . 956 
1633. Encephaloid cancer of lower jaw . 957 
1634. Sarcoma of upper jaw,-specimen in 
University of Pennsylvania . . 961 
1635. Carcinoma of upper jaw . . . 962 
1636. Enchondroma of upper jaw,-Smith's 
collection at University of Penn- 
sylvania 964 
1637. Bony tumor of upper jaw . . 964 
1638. Hypertrophy of tuberosity of upper 
jaw 965 
1639. Lion forceps967 
1640. Metacarpal saw .... 967 
1641. Cutting bone pliers .... 967 
1642. Retractors. 968 
1643. Dissecting periosteal elevator . . 969 
1644. Excision of half of inferior maxilla . 970 
1645. Incision for removal of superior max- 
illa 971 
1646. Position of instruments fur excision 
of same 972 
1647. Rat-toothed forceps .... 976 
1648. Scalpel for staphylorraphy . . 976 
1649. Needles for staphylorraphy . . 976 
1650. Adjuster for staphylorraphy . . 976 
1651. Operation for staphylorraphy . . 977 
1652. Appearance at completion of staph- 
ylorraphy 978 
1653. Instruments for raising the tissues 
from the hard palate . . . 978 
1654. Fergusson's method in cleft palate by 
osteotomy980 
1655. Mode of excising the uvula . . 982 
1656. Adenoid tumor of velum . . . 984 
1657. Insufflator986 
1658. View of the interior structure of a 
healthy tonsil .... 988 
1659. Hypertrophied tonsil laid open . . 988 
1660. Fahnestock's tonsillitome . . . 990 
1661. Physick's tonsillitome . . . 990 
1662. Kolbe's tonsillitome .... 990 
1663. Mode of excising ranula . . . 994 
1664. Salivary calculus from Steno's duct . 998 
1665. Fibrous tumor over parotid gland . 1000 
1666. Tongue-depressor .... 1002 
1667. Pharyngoscopic mirror . . . 1002 
1668. Scraper for pharynx . . . . 1003 
1669. Comb removed from pharynx . . 1012 
1670. General dilatation, with pouches of 
pharynx1013 
1671. Copper penny impacted in oesopha- 
gus,-specimen at University of 
Pennsylvania . . . .1014 
1672. Artificial teeth in oesophagus . .1015 
1673. Bond's gullet forceps . . . 1016 
1674. Gullet forceps1016 
1675. (Esophagus swivel .... 1016 
1676. Horse-ha r snare, closed and open . 1016 
1677. Sponge probang .... 1017 
1678. Carcinoma of lower part of oesopha- 
gus 1019 
1679. Author's oesophageal whalebone 
bougie in one piece . . . 1022 
1680. (Esophageal bougies, with hard-rub- 
ber extremities .... 1022 
1681. (Esophageal diverticulum,-specimen 
at College of Physicians . . 1023 
1682. General dilatation of oesophagus,- 
Ziemssen1024 
1683. Nasal and oral oesophageal tube . 1034 
1684. Gravity apparatus for introducing 
aliment into the stomach . . 1035 
1685. Stomach-pump, complete . . . 1036 
1686. Evacuating the stomach by tube and 
syringe1036 PRINCIPLES AND PRACTICE 
OF 
SURGERY 
CHAPTER XL 
DISLOCATIONS. 
Dislocation (derived from the Latin words dis and loco) and luxation 
(from luxo) are interchangeable terms, and mean the separation and dis- 
placement of one articular surface of a joint from the other. 
Luxations are less common than fractures. Nevertheless, for their recog- 
nition and treatment they demand even a more thorough anatomical knowl- 
edge than the latter. The student, in his dissections, should give particular 
attention to the study of the joints, observing their external contour, their 
form, the relation and movements of their articular surfaces, the disposition 
of their ligaments, the attachment of the surrounding muscles, and their re- 
lation to great blood-vessels and nerves,-a branch of study, I regret to say, 
which is sadly neglected by a large number of medical students. 
Dislocations constitute a class of injuries which are easily overlooked 
unless the greatest attention is given to every case. I am constantly meeting 
with examples of luxations which for a long time have escaped detection ; 
and I suppose my experience is not peculiar in this respect. 
Dislocations are of two kinds, complete and incomplete. 
A complete dislocation is one in which, the ligaments being torn or elongated, 
the articular surfaces of the bones are wholly removed from each other, so 
that the distal surface assumes an entirely new position, more or less con- 
tiguous to the other. 
An incomplete luxation, sometimes termed a partial luxation, or subluxation, 
is one in which, although the relations of the articular surfaces of the joint 
are changed, some portions of them are still in contact with each other. 
As examples of these two degrees of articular displacement, I may mention 
the luxations which affect the temporo-maxillary joint. When the condyles 
of the inferior maxillary bone are removed from the glenoid cavities of the 
temporal bones and thrust into the temporal fossae, the luxation is a complete 
one. If, on the contrary, they are arrested on the eminentiae articulares, the 
dislocation is incomplete. 
Dislocations are also divided into traumatic, pathological, and congenital. 
Traumatic dislocations are such as result from external violence and from 
muscular action. 
Pathological dislocations are those which are consequent upon morbid 
changes of structure in one or more of the components of a joint,-e.g., such 
as occasionally attend coxalgia or rheumatoid arthritis. 
VOL. II.-2 
17 18 
DISLOCATIONS. 
Congenital dislocations owe their origin to the operation of causes which 
affect the foetus in utero. 
Dislocations are further divided into simple and complicated ; primitive 
and secondary; recent and old; unilateral and bilateral; single and 
double. 
Dislocations are simple when no unusual injury of the bones, of the soft 
parts, or of the vessels or nerves, attends the displacement. They are com- 
plicated when an external wound is superadded to the luxation, or when 
fracture of one of the bones involved in the dislocation, laceration of im- 
portant blood-vessels or nerves, or paralysis of the limb also exists. 
Primitive and secondary or consecutive luxations are terms which have refer- 
ence to the position of the displaced bone. Thus, when the head of the 
humerus is thrown into the axilla below the glenoid cavity of the scapula, it 
constitutes a primitive luxation; but if from muscular spasm, or in conse- 
quence of movements from other causes, the head is subsequently changed 
to a point beneath the coracoid process of the scapula, it forms a secondary 
luxation. 
The terms recent and old do not refer chiefly to the time which elapses be- 
tween the reception of the injury and the application for surgical aid, but 
rather to the difficulties which attend the reduction in different luxated joints. 
Thus, a luxation of the elbow-joint becomes old much more rapidly than a 
luxation of the shoulder. The distinction may exist even in dislocations of 
the same joint and of the same duration,-as, for example, where the deter- 
mining cause has been barely sufficient to effect the luxation in one case, 
and in another case has been so violent as to produce extensive damage to 
the articulating surfaces of the bones and the adjacent soft parts, exciting 
intense inflammation and gluing the tissues together. In the first case, the 
restoration would be easily effected, and therefore the dislocation would be 
considered recent; in the latter, the pathological changes, rapidly induced by 
the inflammation, constitute sources of difficulty which ordinarily could only 
arise after the lapse of considerable time, and it would therefore require to 
be treated as though the dislocation were old. 
Unilateral luxations are those in which the bone is dislocated on one side 
only. Bilateral luxations are those in which the bone is luxated on both 
sides. Thus, a dislocation of one condyle of the lower jaw is a unilateral 
displacement, while a dislocation of both condyles is a bilateral one. 
Single dislocations are such as affect a joint on one side. Double dislocations 
are simultaneous luxations of the corresponding joints on both sides of the 
body. 
Causes.-These are predisposing and exciting. 
Predisposing.-Among these may be enumerated the following : 
1. Form of the articulation.-The ball-and-socket joints, from the plan of 
their construction, and from the extensive range of movement which they 
allow, are peculiarly liable to dislocation,-a fact which explains the frequency 
of scapulo-humeral luxations as compared with dislocations of the elbow- 
joint, which belongs to the class of ginglymoid or hinge articulations, whose 
movements are in a great measure limited to flexion and extension. 
2. Defective articular development.-There are cases in which the head of a 
bone and its articulating cavity are imperfectly formed, the one being un- 
usually shallow, and the other small or misshapen, to both of which conditions 
may be conjoined an elongation of the connecting ligaments. Such a con- 
formation is peculiarly favorable to luxation. 
3. Absorption of a portion of the articulating surfaces or ligaments of a joint.- 
This may be the result of a tumor, which, in its growth, comes in contact 
with the components of the articulation; or it may be produced by the 
attrition of the articulating surfaces under peculiar conditions. In this way 
the eminentiie articulares are sometimes worn down on their sides from an 
irregular disposition of the teeth, causing the condyles of the inferior maxilla CAUSES OF DISLOCATIONS. 
19 
to bear, in their movements, with unusual force against a limited portion of 
the glenoid cavities of the temporal bone. 
4. Fracture of an articulating cavity.-When the head of a bone is driven 
against its articulating cavity with sufficient force to chip off a portion of 
the margin of the latter, luxation of the joint will almost invariably follow. 
The accident has frequently happened to both the hip- and the shoulder-joint. 
5. Muscular weakness.-When the muscles about a joint become paralyzed 
or enfeebled from any cause, they allow the head of the bone to drop, and the 
weight gradually causes the ligaments to become elongated, and finally to 
allow the bones of the articulation to be luxated. An interesting case of this 
nature came under my notice, in which the scapular muscles of both sides 
had gradually lost their power and become atrophied, and thus allowed the 
humerus to become displaced. The scapula had wasted to a remarkable 
degree. Sir Astley Cooper describes two similar cases, in one of which the 
bone could be thrown out of place at pleasure. 
A subluxation of the inferior maxilla, from muscular relaxation, is fre- 
quently noticed in weak, anaemic females. 
6. Articular disease.-Large inflammatory transudations into the joints, 
causing elongation of the ligaments, or the reflex contraction of the muscles 
about an articulation already excited by arthritic inflammation, are both pre- 
determining causes of luxation. It is in this way that the patella and the 
bones of the leg are sometimes dislocated. 
7. Age.-Dislocations are exceedingly uncommon in very young subjects,- 
a fact no doubt to be ascribed to the absence of great muscular power, the 
presence of the epiphyseal cartilages, and the general flexibility of the tissues 
composing the joints. These injuries are most common in the middle period 
of life, that is, between thirty and sixty, and diminish in frequency very 
rapidly after sixty. Of 912 cases of dislocation received into the Pennsylvania 
Hospital, 589 were in persons between the ages of thirty-five and sixty-five, 
only 44 occurring after the last-named period. Malgaigne, in an analysis of 
643 dislocations, found 407 of this number to have taken place between the 
ages of thirty-five and sixty-five, and only 1 case under five years of age. 
8. Sex.-Males are much more frequently the subjects of the accident than 
females. Of the 912 cases to which reference has been made, 88 per cent, 
were males. But, as regards age and sex, it must not be forgotten that the 
exposure incident to middle life and the character of its occupations exercise 
no small influence in determining the results reached by statisticians. 
Exciting Causes.-The exciting causes of dislocation are external force 
and muscular contraction. As in fractures, so in luxations, this external force 
may be either direct or indirect. If a person falls upon the shoulder and 
dislocates the head of the humerus, the bone is displaced by direct violence; 
when the force is applied to the hand or the elbow, and a similar result follows, 
it is an example of luxation by indirect violence. 
The part which the muscles play in dislocation is not altogether clear. I 
apprehend it is a very subordinate one. For several years I was in the habit of 
demonstrating on the cadaver, to my classes in operative surgery, the facility 
with which luxations could be made by movements in which the muscles of 
course could not participate. That the muscles are capable, under an ex- 
traordinary stimulus, of producing dislocations, is indisputable. Several times 
have I seen such displacements of the head of the humerus, which took place 
in the night during epileptic convulsions. 
Symptoms.-The symptoms of luxation are the following. There is pain, 
which, though not so acute as in fracture, is almost as difficult to endure. 
This pain is much increased on movement of the part. It is dull, and due 
to pressure upon the surrounding nerves, or to tension of the latter. Some- 
times the discomfort complained of is numbness, as when the head of the 
humerus rests against the axillary plexus of nerves, or the head of the femur 
presses the great ischiatic cord. 20 
DISLOCATIONS. 
Loss of function.-The limb or the part dislocated is no longer capable of 
executing the ordinary movements, but, as a rule, is rigid and fixed, and in 
this respect dislocation differs from fracture. This symptom is much more 
marked after the lapse of a few hours than immediately after the injury, i.e., 
after the muscles have recovered from the paralyzing effects of the shock 
and the surrounding parts have become swollen. 
Swelling is of little importance as a symptom. Like that in fracture, it is 
due to either blood or serum, or to both. When appearing quickly and to 
any great degree, it is usually from the effusion of blood. 
Change in the length of the limb.-When the articulating surfaces are re- 
moved from each other this change inevitably follows, and consists in shorten- 
ing, always in dislocations of the hinge-joints, and generally in those of the 
ball-and-socket form. To restore the limb to its proper length requires the 
employment of much greater force than is necessary to effect the same result 
in fracture. 
Change in the direction of the limb.-This is due to the tension of the 
unbroken part of the ligaments, to the traction of certain muscles, and some- 
times to the resistance of bony surfaces which normally are not in contact. 
Hence we have the elbow standing awkwardly off from the body in disloca- 
tion of the scapulo-humeral articulation, and adduction or abduction, with 
rotation, in luxations of the hip, etc. 
Change in the exterior of the articulation.-Every joint presents certain topo- 
graphical characteristics and has an expression peculiar to itself. These 
depend in a great measure upon the bones beneath, so that when the rela- 
tions of the latter are changed, the outlines of the articulation are materially 
altered. Thus, normal rotundity is exchanged for flatness; bony processes 
which are scarcely noticed, as the acromion, become, in luxation of the 
shoulder, abrupt and salient; or the prominences may sink out of sight, as 
is the case with the trochanter major in luxation of the hip. Certain muscles 
also, in the direction of the displacement, become shortened and are bulging, 
while others, put upon a stretch, form tense cords beneath the skin. The 
head of the luxated bone may be often felt in an unusual position. 
To recognize these symptoms fully, the corresponding sound side should 
always be exposed. When the swelling is great, the difficulties are enhanced ; 
but even then a careful consideration of the points which have been enu- 
merated will usually conduct the surgeon to a just conclusion, especially if 
he brings to his aid the use of an anaesthetic. 
Crepitus.-This symptom, when present, is the result of the movements of 
tendons through inflamed sheaths or over bursae, and of the friction of a 
cartilaginous surface against bone. It is very unlike that present in fractures, 
being soft and subdued, instead of rough and grating, as in the latter. 
Discoloration, of itself, is a negative sign, but, as a rule, makes its appear- 
ance later than when due to fracture. 
Diagnosis.-That the distinguishing signs between dislocation and fracture 
may be clear, they may be contrasted in the form in which they are placed 
below. 
DISLOCATIONS. 
Pain dull, though severe. 
Diminished mobility. 
Change in the external contour of the joint. 
Crepitus, when present, is a soft or friction 
sound. 
Require much force to overcome shortening; 
and when corrected, there is no tendency to recur. 
Limb assumes a stiff, awkward appearance, 
projecting from the body. 
FRACTURES. 
Pain acute. 
Preternatural mobility. 
Not invariable: when it does occur, it is swell- 
ing. not flattening. 
Crepitus rough and grating. 
Little force required; the deformity recurring 
when that force is withdrawn. 
Limb has a helpless, dangling, or limp appear- 
ance, approaching rather than receding from the 
body. 
To distinguish dislocations from a separation of the epiphyses, we are to 
remember that the latter can occur only in young subjects, or at an age when PATHOLOGICAL EFFECTS OF A DISLOCATION. 
21 
dislocations are among the rarest of accidents, and that crepitus is generally 
present in epiphyseal injuries. 
Luxations may be distinguished from sprains by the facts that in the latter 
the movements peculiar to the joint, though painful and somewhat restricted, 
can all be made by the hand of the surgeon, and that the deformity consists 
of swelling alone. 
Pathological Effects of a Dislocation.-These involve all the structures ad- 
jacent to the displaced bones. They may be divided into immediate and 
remote. 
. The immediate effects consist partly in the laceration, tension, etc., of a por- 
tion of the ligamentous apparatus of the joint. The capsular ligament is rent 
in the enarthrosis form ot articulation, and sometimes other ligaments are torn, 
as the ligamentum teres in the hip-joint, and, in the ginglymoid joints, portions 
of those situated on one or more aspects of the articulation. In partial dis- 
placements, especially of the first kind (or ball-and-socket articulations), 
rupture of the capsule is not a necessary consequence; and perhaps the same 
may be true, occasionally, even in a complete luxation, when the capsule has 
been much elongated by muscular enfeeblement, although I am not aware of 
the existence of any specimen which establishes this statement. Holmes* 
mentions a preparation of a shoulder-joint in the museum of the College of Sur- 
geons, dissected by John Hunter, three weeks after the reduction, and which 
is thought to be of this kind. In addition to the laceration of the ligaments, 
the tendons and muscles likewise suffer, being stretched, bruised, or torn. 
Small vessels are ruptured, principally veins, and extravasations of blood are 
found in the joint and among the tissues, in the neighborhood of the bones. 
It is astonishing that the large vessels should so generally escape serious 
injury. That these may, in exceptional instances, be damaged, is seen in the 
case recorded .by Professor Goldsmith,j- where the head of the femur, which 
had been dislocated upon the pelvis above the acetabulum, lay in a large 
aneurismal dilatation of the femoral and external iliac arteries. 
. The nerves also are frequently subjected to pressure, stretching, and lacera- 
tion, causing numbness, loss of power, and neuralgic suffering. The articular 
surfaces of the displaced bone or bones may be partially In contact or be 
widely separated,-conditions depending upon the intensity of the deter- 
mining violence, on the degree of ligamentous laceration, and on the favor- 
able disposition of muscles to act upon them. In two cases which I had 
an opportunity of dissecting, long after they had been reduced,-the one a 
shoulder, the other a hip,-scarcely could I discover a trace of the former 
injuries. 
The remote effects of a luxation are of a very pronounced character. 
They reach both to the bones and to the soft parts, and they illustrate in a 
remarkable manner the power of accommodation to unusual conditions 
which resides in the body. When the bone remains unreduced, the old liga- 
ments undergo wasting, and in time cannot be distinguished from the sur- 
rounding connective tissue; the head of the bone becomes atrophied and 
flattened, and its cartilaginous incrustations disappear, the surface below 
becoming smooth, hard, and polished. The articular cavity grows more 
shallow and loses its regularity, and may eventually disappear by the opera- 
tion of two agencies,-the absorption of its circumference and the production 
of fibrous tissue or bone from the bottom of its cavity. 
Wherever the head of the displaced bone rests, it produces for- itself a 
cavity designed to supply the place of the old one. If it lies on a muscle, 
tendon, or fascia, there will be a rapid formation of condensed connective 
tissue, which assumes a cup shape; if it lies against a bone, a cavity will 
be developed, partly by absorption, and partly by a new deposit of osseous 
matter, the latter rising from the surface and forming a socket not unlike the 
original one, with an eburnated instead of a cartilaginous surface. 
's Surgery, vol. ii. p. 103. f American Journal of Medical Sciences for July, 1860. 22 
DISLOCATIONS. 
But the work does not stop here. The movements of the bone stimulate 
a further development of connective tissue, the interlacing fibres of which, 
becoming close and compact, 
serve to play the part of the 
old capsular ligament, the in- 
terior of which may, like other 
bursal sacs, furnish a fluid 
which will serve to lubricate 
the improvised joint. Some- 
times the work is overdone, 
and the osseous deposit, which 
is piled up to form the socket, 
girdles the head or neck of the 
bone too tightly and interferes 
with its movement. The mus- 
cles, either stretched or short- 
ened by the luxation, undergo 
a fatty Change and become 
wasted; or, if torn so that the 
ends do not become united, 
they entirely disappear. The 
surrounding tendons, if torn, 
may, if much displaced, con- 
tract an attachment to other 
points; they may also have 
nodules of bone deposited in 
their substance. Inflamma- 
tory changes, in the mean 
time, have also been active, 
matting together the diverse 
structures of the part, and, 
most dangerous of all, gluing 
large blood-vessels to the capsule investing the bone or its periosteum and 
exposing the patient to fatal hemorrhage when forcible efforts are made at 
reduction. 
In old cases of unreduced ginglymoid joints, the repair is much less com- 
plete. The rapidity with which these changes are effected varies so much 
that no deductions of a practical nature can be made with any degree of 
certainty. In young persons it is certainly much more rapid than in the 
aged. Hilton, Hamilton, and others have seen very considerable progress 
made towards the formation of a new joint at three weeks, and as early as 
the eighteenth day. Brodhurst* describes a case of three years' standing, 
and Fournier a similar one seen ten years after the luxation, in both of which 
the cotyloid cavity of the innominatum Avas unchanged. 
Prognosis.-In recent luxations, the reduction is usually accomplished 
without much difficulty; but some defect in the movements of the joint, and 
neuralgic pains, often continue for a long time after. I have seen many dislo- 
cated shoulders which ever after were disabled by inflammatory changes in 
and around the joint. The enarthrodial articulations are more easily displaced 
than the ginglymoid. The lattei' are made very secure by the processes and 
deep fossa; which belong to the articulating bones, and by the powerful liga- 
ments and strong muscles which are disposed about the different aspects of 
the joint; so that to luxate such an articulation requires immense force, which 
is generally the measure of structural damage. The enarthrodial joints are 
at first more difficult of reduction than the ginglymoid ; later the reverse is 
true. 
Every year strengthens my belief that, as a rule, an articulation once dis- 
Fig. 898. 
A new socket formed on the dorsum ilii by the displaced head of 
the femur, a. External view of the new cavity, b. Its floor in- 
side of the ilium. 
* St. George's Hospital Reports, vol. iii. p. 68. REDUCTION. 
23 
located is rarely entirely restored to its original condition, but ever after 
manifests some weakness, defect of movement, or disordered sensibility. 
Treatment.-In the treatment of luxations, the same rule should be observed 
as in fractures, namely, to restore the bones to their proper functional position; 
to prevent a recurrence of the displacement; to combat any undue inflam- 
matory symptoms which may arise, and to establish the natural movements 
of the part. Reduction should be made at the earliest possible moment. 
There are cogent reasons for such a course. One of the great obstacles en- 
countered in reducing a luxation is muscular resistance. Immediately after 
such an accident the muscles are temporarily paralyzed, and consequently 
incapable of offering much opposition. The patient is also shocked, and, 
therefore, less sensitive to pain than hours after, when the initiatory stage 
of inflammation sets in, and the surrounding parts become swollen and 
tender. 
THE MEANS TO BE EMPLOYED. 
Manipulation.-One of the grand triumphs of modern surgery, it is some- 
times said, is the substitution of address for brute force in the treatment of 
recent luxations. It will be found, however, that in the treatment of disloca- 
tions, as in many other branches of the art, we are only repeating and re- 
ducing to more practical forms the resources of the men of a former period. 
It is only after exploring the treasure-houses of these old-time workers that 
we begin to form any just conception of the immense fertility of expedients, 
the vast acquisition of knowledge, and the majestic sweep and reach of the 
thoughts which belong to the fathers of ancient medicine. Hippocrates dis- 
tinctly speaks of reducing luxations by flexion and rotation of the injured limb; 
and during almost every succeeding century there have not been wanting 
writers who were entirely familiar with the same method. Richard Wiseman, 
that good old English surgeon, before 1676 was perhaps as familiar with this 
plan of reduction as Mr. Birkett in 1854. Over one hundred years ago, the 
fallacy of employing force alone for the reposition of dislocations was de- 
tected by Thomas Anderson,* in Scotland, and by Poteau,f in France, and 
manipulation employed as a substitute. Kluge's plan, in thigh dislocations, 
was to place the patient on his back, and, by flexion, abduction, and rota- 
tion, to restore the head of the bone to its Colombat claims to 
have been always successful in reducing luxations of the thigh, by making 
his patient lean over a table, and at the same time seizing its sides in order 
to keep the body fixed. While so placed, the leg was flexed on the thigh, 
and the latter drawn back and forth, and from side to side, until the bone 
slipped into place.§ Palletta's plan consisted in forcible flexion and abduction 
of the thigh.|| 
In this country, reduction by manipulation was first practiced by Dr. 
Physick, in 1811, and five years later by N. Smith, of New Haven.But 
for the fullest exposition of reduction by manipulation the profession is in- 
debted to Dr. W. W. Reid, of Rochester, New York, who in 1851 published** 
a detailed account of the plan which he pursues for the reposition of coxo- 
femoral dislocations. It consists, after placing the patient in the recumbent 
position, in first flexing the leg on the thigh, then adducting the limb, 
carrying it over the sound one, and, at the same time, upwards over the 
pelvis, by a semicircular sweep as high as the umbilicus. The knee is now 
to be gently abducted and rotated, when, as the limb is brought downward, 
the bone (if the luxation is dorsal) will glide into its articulating cavity. 
® Anderson's Medical Commentaries, Edinburgh, 1776, vol. ii. pp. 261-264, Hamilton, 
f Vidal de Cassis, CEuvres posthumes de Poteau, Paris, 1783, Hamilton. 
f Dissert, de luxatione femoris, vol. ii. p. 241, Berol., 1823. 
§ Op. cit., p. 706, Chelius. || Chelius, vol. ii. p. 242. 
Transactions of New York State Medical Society for 1856, p. 169. 
Buffalo Medical Journal, August, 1851. 24 
DISLOCATIONS. 
The reduction of scapulo-humeral dislocations by manipulation was first 
reduced to systematic rules by Professor H. H. Smith, of Philadelphia. 
Manipulation proceeds upon an accurate knowledge of all the anatomical 
components of a joint in its normal state. To employ it intelligently, the 
surgeon should also know, approximately at least, where the rent in the 
ligaments has been made, what ridge of bone will oppose, what muscles will 
resist, and what others can be won to his aid. In most cases, if acquainted 
with these facts, we shall succeed in restoring the dislocation. 
Anaesthetics constitute a powerful auxiliary to the reduction, and, unless 
there be contra-indications, they should always be employed as a preliminary 
measure. When the patient is seen at the time or within a few minutes after 
the dislocation has occurred, the necessity for their employment is less urgent. 
The boon which has been conferred on the surgery of luxations by ether and 
chloroform can only be appreciated by those who have, not many years ago, 
witnessed the reduction of a dislocation, such, for example, as that of the 
hip. The unfortunate patient was first subjected to the depressing effects 
of venesection while in the warm bath. Tartar emetic was next adminis- 
tered, until he was pale, sick almost unto death, and covered wuth a profuse 
perspiration. There was next attached to the injured limb a formidable 
enginery of compound pulleys, and extending and counter-extending bands, 
manned by rows of assistants, presenting altogether a scene strangely sug- 
gestive of mediaeval torture. Even intoxication was resorted to in some 
instances to insure muscular relaxation. 
Force.-Cases will be encountered in w'hich manipulation will fail, and 
where force must be employed by other means, as in luxations of some weeks' 
standing, and in those which are called old. The appliances used in these 
cases, with the manner of 
their application, will now 
be detailed. 
Position of the Pa- 
tient. - The recumbent 
position, on the back, upon 
a table, or on a narrow 
bed, is the one best suited 
for the reduction of dislo- 
cations of the lower extre- 
mity and of the shoulder, 
whether by manipulation or by more forcible means. The others are most 
conveniently treated in the upright or sitting posture. 
Extension and Counter-Extension.-These operations are best effected 
by strong muslin sheets 
folded into cravat form, 
by bands of stout muslin, 
by long double or jack 
towels, by means of the In- 
dian basket, and through 
the power of pulleys. 
They should be made 
fast, as a rule, when it is 
possible, to the distal end 
of the dislocated bone; 
for example, above the 
elbow in luxation of the 
humerus, or above the 
knee in luxation of the 
hip. This adjustment 
leaves the forearm or the 
leg free to be used as an arm of a lever. To prevent excoriation of the 
Fig. 899. 
The noose knot. 
Fig. 900. 
The noose knot applied to the arm. REDUCTION. 
25 
soft parts, and to avoid slipping, it is common to envelop the part with a wet 
piece of muslin or chamois leather, and then to apply over this the band. 
There are two knots which do not slip, either of which may be made. The 
first is called the noose (Fig. 899), and is made by folding a sheet into cravat 
form, doubling it at the middle, and, after drawing each half partially through 
the noose, slipping it over the limb. (Fig. 900.) 
The other knot is the clove-hitch, which will be best understood by looking 
at Figs. 901 and 902. 
Fig. 901. 
Fig. 902. 
Clove-hitch. 
Clove-hitch knot applied. 
The Indian basket, which is a hollow cylinder woven of twigs of the 
willow or of strips of other wood (Fig. 903), constitutes a good instrument 
for securely grasping a part. By pressing together the ends of the basket 
the canal is enlarged, when it can be slipped over the limb, after which, 
the greater the extension the more firmly will it cling to the surface. 
Fig. 903. 
Fig. 901. 
Indian basket. 
These contrivances are sometimes 
woven round a ring of iron at one 
extremity, the ring having two 
hooks or eyes for catching the ex- 
tending bands, and may be applied 
to the arm or the thigh. (Fig. 
904.) 
The rope-windlass, as employed 
by Dr. Gilbert, is another ap- 
pliance by which great power can 
be exercised. It can be quickly constructed by running a rope through 
the loop of either the noose or the clove-hitch, and securing the two ends 
together. When ready to apply the force, the end of the rope should be 
passed over a hook, or, before its ends are tied together, run through the 
eye of a staple. By twisting a stick placed between the two portions of the 
rope (Fig. 905) an unusual degree of power may be attained. 
If it is desirable to obtain still greater mechanical power, the compound 
pulley (Fig. 906) can be used. 
Indian basket applied to the arm. 26 
DISLOCA TIONS. 
When these energetic means for extension are employed, the counter-exten- 
Fig. 905. 
Gilbert's rope-windlass applied to the arm. 
sion must be applied so as to fix the upper portion of the articulation, as by a 
Fig. 906. 
Compound pulley. 
perineal band in dislocation of the hip. (Fig. 907.) The ends of the band 
Fig. 907. 
The application of the pulleys. 
should be made fast to a staple or hook (Fig. 908), or to some other firm 
object, always observing to defend the skin against the effects of pressure. REDUCTION. 
27 
Nothing answers the latter purpose better than a hank of yarn, when this 
can be had, placed under the counter-extending bands. 
In order to measure the degree of force which may be used 
in restoring a luxation, or rather that the force may not be 
applied beyond the bounds of prudence, the French sometimes 
use an attachment to the pulleys, called the dynamometer. 
An instrument of great power is one invented by Jarvis, 
commonly known as Jarvis's adjuster. It is a mechanism 
which exerts at the same time extending and counter-ex- 
tending force. It is both costly and complex, and at present 
is very rarely employed. The tourniquet of Bloxam, at one 
time used in the reduction of dislocations, is another appli- 
ance which has in a good measure passed into disuse. 
Dr. Davis, of New York, recommends india-rubber bands, 
which, by their elasticity, are well adapted for continuous ex- 
tension. By the use of this material the doctor claims that 
he succeeded in reducing a luxation of the hip of fourteen 
years' standing. 
This matter of continuous extension cannot be over-estimated, especially in 
restoring old dislocations. South relates a case of dislocated shoulder which 
had successfully resisted all the ordinary efforts for reduction, but which was 
reduced by the younger Clive by first fixing the shoulder and then suspend- 
ing an ordinary brick from the hand over the side of the bed. On the day 
following, when he visited his patient, the head of the bone had resumed its 
place in the glenoid cavity. In a dislocation of the elbow-joint of six months' 
duration, continuous pulley-extension, protracted for eight hours, was at- 
tended with a like favorable result. 
Fig. 908. 
Staple having a 
screw by which, 
after first boring a 
hole with a gimlet, 
it can be screwed 
to a post, or into 
the floor. 
Mode of Using Force.-First, the force should be exerted in a proper di- 
rection. Second, it should not be made in a spasmodic or violent manner, 
but continuously, and with a gradual increase of power. Third, the part 
must be rotated and moved in all directions, so as to disengage the head of 
the bone from any lock or entanglement and break up such adhesions as may 
have formed between it and adjacent structures. A.x\d, fourth, when resistance 
of the muscles has been so far overcome as to allow the head of the bone to 
reach the level of the cavity from which it has been displaced, an adroit 
movement of the part must be made by the hands of the surgeon towards 
that cavity, while at the same moment the extending force, at a given 
signal, should be suddenly relaxed. 
Should these measures fail, after being repeated and modified as the in- 
genuity and judgment of the surgeon will suggest, the question of dividing 
subcutaneously such ligaments, fibrous bands, tendon or tendons as are 
ascertained to prevent the restoration will come up; and its decision must 
be determined by a well-grounded assurance that the reduction is highly 
improbable without the operation. 
Dieffenbach, Blumhardt, and others have, in this way, succeeded in restoring 
luxations of the shoulder and elbow of long standing. The operation is not 
unattended with danger to vessels and nerves, even in the most skillful hands, 
and can rarely be required. 
When a dislocation is reduced, the fact may be known by the more or less 
perfect restoration of the natural outlines of the articulation, by the freedom 
of movement, and by the proper direction of the limb. The pain is diminished, 
and often the reduction is announced by a distinct sound. The use of anaes- 
thetics may, however, prevent this last sign from being present, the bone, 
under the great muscular relaxation, going into place silently. 
After-Treatment.-The bones once reduced, care must be exercised to pre- 
vent a recurrence of the displacement, by applying such retentive dressings 
as will be noticed under the head of Special Luxations. And, lastly, an- 28 
DISLOCATIONS. 
chylosis must, if possible, be prevented, by establishing at the proper time 
-say from ten to fourteen days-the various movements of the part, and 
renewing these movements daily. 
Complicated Luxations.-Various circumstances may complicate a luxation. 
Some of these attend the accident. That is, the same force which determines 
the dislocation produces the additional injury which constitutes the compli- 
cation. Others arise during the attempts at reduction. Some are serious, and 
others are comparatively unimportant. 
Fracture.-A fracture coexisting with a luxation of the same bone adds 
no small difficulty to the case. But the course to be adopted is clear. The 
broken bone should be immediately set, covered with a bandage, and sur- 
rounded with a number of narrow splints, well padded, and bound securely 
to the part by a second roller. An anaesthetic should next be administered; 
and, when thorough relaxation is obtained, the manipulation necessary to 
the reduction of the luxation must be executed. Should it become necessary 
to attach extending bands, they must be applied over the splints, and, if 
practicable, above the seat of fracture. Should the fracture occur in the 
surgical neck of the humerus, the head of the bone being at the same time 
dislocated, of course the application of a splint previous to reduction is 
impracticable. Here the surgeon must rely, after etherization, upon well- 
directed pressure against the liead of the bone, and, if successful in restoring 
it, afterwards apply the dressing appropriate to a fracture in this part of 
the humerus. 
Compound Luxations.-The existence of an external wound communi- 
cating with the luxated joint is always a most serious injury. The cavity of 
the articulation may be opened by the soft parts being torn from without 
inwards, from the direct action of violence; but generally the reverse is 
true, the wound being caused by the dislocated bone being driven through 
the integuments. The dangers incident to so serious a complication are 
destructive arthritis, abscesses, pyaemia, erysipelas, necrosis, tetanus, hemor- 
rhage, etc. Frequently the end of the bone is broken in addition to the other 
damage. As compared with simple luxations, compound luxations are 
quite rare. Dr. Norris, in his statistics drawn from the records of the 
Pennsylvania Hospital, found in 94 dislocations only 2 which were com- 
pound. Hamilton, in a collection of 166 cases, found 8 of a similar kind. 
The table of Dr. Alison* contains 784 cases of dislocations, 56 of which were 
compound. 
The symptoms are so manifest that their detail is scarcely necessary. The 
white, moist, glistening cartilaginous surfaces of the bones, the flow of syno- 
vial fluid, recognized by its unctuous feel, perhaps the exposure of tendons, 
distortion of the part, and subcutaneous discoloration, sufficiently declare the 
nature of the injury. 
Treatment.-This often demands the exercise of a well-instructed judg- 
ment. If the articulation is small, like a phalangeal or a metacarpo-phalangeal 
one, the parts should be replaced, well sprayed with carbolated water, the 
external wound carefully closed and covered with a Lister dressing, and the 
hand placed upon a palmar splint, the finger being slightly flexed in the 
position which will render it most useful to the patient should anchylosis 
follow. If antiseptic dressing is not applied, the articulation, after its closure, 
should be covered with lead-water, and laudanum frequently applied, which 
may be renewed once in six hours, at the same time observing to disturb the 
parts as little as possible until the external wound is closed. After it is 
closed, gentle movements should be made, to restore, if possible, the function 
of the joint. 
When the injury befalls large articulations, such as the ankle, the knee, 
the elbow, the shoulder, or the wrist, the case assumes the highest impor- 
* Alison's Manuscript Tables of Luxations at the Pennsylvania Hospital. COMPOUND LUXATIONS. 
29 
tance, and the line of conduct must be settled by a careful consideration of 
several points. 
1. If the patient is somewhat advanced in years, or is of intemperate 
habits, with a constitution impaired or broken by excesses, any attempt to 
save the limb, except in the case of a compound dislocation of the shoulder, 
will, in all probability, fail. It should be amputated at once. 
2. If the soft parts are extensively lacerated and the ends of the bones 
comminuted, excision or amputation will be demanded. The elbow-, the hip-, 
the shoulder-, and perhaps the ankle-joint, provided the soft parts are not 
too much torn, are best treated by excision. If the knee is the implicated 
articulation, amputation will be required, except in the case of children or 
in very young persons. Then excision should be preferred. 
3. Where the principal blood-vessels are torn, with extensive damage to 
the soft tissues, amputation is proper. 
Should there be two vessels supplying the parts below, as the tibials at the 
ankle, or the radial and ulnar arteries at the wrist, the rupture of the least 
important one, as of the anterior tibial, or of the radial, does not of itself 
necessitate amputation. The torn vessel should be tied, the remaining artery 
being equal to the supply. 
If, after having considered the case in all its bearings, the surgeon decides 
to make an attempt to save the limb, the dressing must be made. The joint 
should be placed at once under the antiseptic spray. All vessels which con- 
tinue to bleed must be tied, and, if possible, a fracture-bed provided. If 
there are any foreign matters adherent to the surfaces of the displaced 
bones, or to other parts, they must be carefully washed off with warm water 
directed upon the wound by a sponge or from the nozzle of a syringe. Any 
loose fragments of bone must also be picked away with the fingers, or by the 
forceps, enlarging the external opening, if necessary, for this purpose. In 
the case of the ankle-joint, when the astragalus is detached or broken, the 
latter should be removed in its entirety. 
At this stage a very important question presents itself with regard to the 
ends of the bones. Should they be returned as they are, or should they be re- 
moved? Of course I mean that this question arises only in those cases in 
which the articulating surfaces remain uninjured. Where spiculje or irreg- 
ularities are present, the consequence of fracture, the propriety of removing 
them can scarcely be said to admit of any doubt. Without entering into 
the discussion of this subject, I may say that in my experience it is the 
safest course to cut away the displaced ends of the articulating bones. That 
a good result may occasionally be obtained without such an operation I 
admit, but it is exceptional, and should not be allowed unduly to sway our 
practice in this respect. In restoring the bones, even after the preliminary 
section, difficulty is sometimes encountered. Should, then, the ordinary 
manipulation for this purpose fail, the obstacle will probably be found in a 
constriction of the soft tissues about the bone. To overcome this, they may 
be stretched apart by the use of retractors. This failing, the opening should 
be enlarged by incision. When the resistance is due to the tension of certain 
muscles or tendons, an alteration in the position of the limb may secure their 
relaxation, or their division by means of tenotomy may be required. This 
not only facilitates reduction, but also renders the future treatment of the 
case more satisfactory. 
The bones being restored, the external wound must be carefully closed by 
metallic sutures and then covered with the Lister dressing. 
If the antiseptic treatment cannot be adopted, next in value will be irriga- 
tion with cold water. An exceedingly important part of the future manage- 
ment of the case is the securing of absolute quiet of the joint. This can be 
best effected, in the case of the knee articulation, by Packard's bracketed 
splint (see cut, vol. i. p. 970), by the long fracture-box and bran, or, what is 
preferable, by recurring turns of a plaster roller including three-fourths of 
the circumference of the limb and extending from a little distance above the 30 
DISLOCA TIONS. 
ankle to the upper third of the thigh. A trap can be subsequently cut in 
the splint directly opposite to the wound, through which the latter can be 
dressed. The limb can be suspended in this dressing if the patient is dis- 
posed to be restless. This last appliance, or, if it is not accessible, that of 
the short fracture-box with bran, answers very well for the treatment of 
compound luxations of the ankle-joint. The McIntyre splint is used by some 
for the same purpose. 
When it is necessary to employ compression, it should be done by a Scul- 
tetus bandage,-an arrangement which admits of the removal of the strips 
and of their being replaced by others with a minimum disturbance of the 
parts. To effect this substitution, it is only necessary to attach to the end 
of each piece another of like size, which will take the place of the first as 
the latter is drawn away. 
In compound luxations of the shoulder-joint, the arm may be placed upon 
an internal angular or trough-shaped splint, and fastened to the body by the 
turns of a roller. 
When the elbow is the subject of the accident, the internal angular splint 
may be used, or a trough-shaped one, made of leather, wire, or plaster. 
For the wrist, the ordinary palmar splint, employed in fractures of the 
carpus or metacarpus, answers every indication. 
Occasionally the tibia is broken at the lower epiphysis and the diaphysis is 
at the same time thrust through the external wound. The accompanying 
cut (Fig. 909) represents an accident of this kind in a lad,-one of my 
hospital patients. The treatment in a case of this nature does not differ 
from that proper in compound luxations, except that in the 
former there is no necessity for cutting off the ends of the 
diaphysis. 
During the period of traumatic fever the excitement must 
be moderated by the exhibition of some febrifuge, as the 
neutral mixture, given at intervals of two or three hours, 
each dose containing the fortieth of a grain of antimony 
and the twentieth of a grain of morphia. The nourish- 
ment for the first few days should consist of liquids. If 
the local inflammation exceeds the limits of safety, leeches 
should be freely distributed about the joint. When the in- 
flammatory storm is past, it will be necessary to direct a 
generous diet and to administer quinine and iron. The 
articulation should be disturbed as little as possible, since 
every movement is provocative of evil. The external cold 
or water dressing, if such has been used, may be gradually 
withdrawn as the wound heals, applying adhesive strips as 
a substitute. 
Under the most judicious management the joint may do 
badly. Erysipelas may supervene; abscesses may form, 
followed by profuse suppuration, by necrosis, and even by 
mortification. The system necessarily experiences the 
greatest disturbance in such a state of the parts. The 
pulse grows small and frequent; the tongue becomes dry 
and is streaked with patches of brown fur; the mind wanders; the surface 
is bedewed with a clammy perspiration ; all the symptoms indicate a 
rapidly fatal termination. 
To amputate in such a perturbed state of the body would only precipi- 
tate this result. If the patient can be tided over this danger by the use 
of stimulants, by nourishment and opiates, with the local use of warm 
poultices, and the prompt liberation of purulent accumulations as they form, 
the disease may be arrested at the point of necrosis, or a line of demarka- 
tion may be established should gangrene have taken place, and a general 
improvement may follow, foreshadowing a period, not very remote, when 
an amputation may be done with a good prospect of success. 
Fig. 909. 
/ 
Compound sepa- 
ration of the tibia 
at its lower epiph- 
ysis. OLD LUXATIONS. 
31 
Should gangrene set in, unassociated with the aggravated symptoms indi- 
cated above, amputation may be immediately resorted to. 
Old Luxations.-In old cases of luxation, which have been overlooked, or 
in which only the ordinary efforts have been made for reduction, sAouZd 
further attempts be made to correct the displacement ? 
A person with a dislocated joint must always remain under a great dis- 
ability, and no case ought to be abandoned, except from a full persuasion that 
further attempts would jeopardize the life of the patient. The fear that failure 
compromises professional reputation may urge a surgeon forward when his 
judgment would counsel otherwise; and I am well convinced that it requires 
no small degree of courage to say, " I have failed." But human life should 
never for one moment be placed in the balance against professional pride. 
So that while a tendon may be torn, a vessel lacerated, or even a bone broken, 
in lawful efforts at reduction, there can be no extenuation for that reckless 
use of force which, in the hands of a French surgeon, once tore off the fore- 
arm of an aged woman at the elbow, while trying to reduce an old luxation 
of the shoulder;* or, as in Flawbert's case, for lacerating the brachial plexus 
of nerves ;f or for pulling off a phalanx in vain attempts to restore a luxated 
thumb.J 
It is difficult to determine the period at which the surgeon should decline in- 
terference in an old luxation. The dangers are certainly increased when there 
has been a history of much inflammation following the accident, thus gluing 
together the parts about the bone; and when the limb allows of but little 
movement. Smith, of New Haven, succeeded in restoring one shoulder after 
seven months, and another after ten and a half months. Breschet narrates the 
case of a hip reduced at seventy-eight days, also one of the shoulder at the 
eighty-second day, one at the ninetieth, and one at the ninety-eighth. Travers 
reduced a hip five months after the accident; Hr. Blackman, of Cincinnati, 
six months after; and Dr. Smyth, of New Orleans, nine months after. In 
the " Memoirs of the Royal Academy of Paris," vol. v. page 529, a case of 
dislocated hip is recorded which was reduced after a lapse of two years ;§ and 
Brodhurst restored a shoulder on the one hundred and seventy-fifth day. Of 
thirty-seven cases collected by Dupuytren, ranging from one week to two 
years, all were reduced except two, which had been of the longest duration. 
The oldest one restored was of eighty-two days' standing. Other cases of like 
nature might be quoted. Sir Astley Cooper made three months the limit at 
which it was proper to attempt a reduction of the shoulder, and eight weeks 
for one of the hip. The use of anaesthetics must materially modify any such 
limitations; and when in addition to this our present knowledge of manip- 
ulation is considered, I have no hesitation in extending the period much 
further, always, however, apprising the patient of the possible danger at- 
tending the effort to reduce the bone, and never undertaking the task against 
his wish. 
When the surgeon undertakes the reduction of an old dislocation, the 
operation requires a preliminary treatment. This consists in the daily use 
of manipulation, in which the arm is to be moved in all directions, gently 
and only for a few minutes at first, increasing the strength and the time of 
these motions as the limb is found to tolerate them. After each such treat- 
ment the shoulder should be surrounded with a lotion of laudanum and 
water. The objects of these measures are to break up, to soften, and to 
secure in some degree the removal of the bands of lymph by which the 
end of the bone is glued to the surrounding structures. When this is ac- 
complished,-a result which may be known by the freedom with which the 
bone moves in its unnatural position,-an effort may be made to reduce the 
luxation. 
* Gazette Hebdomadaire, 1864, p. 289. 
f Repertoire Generale, tome iii. 
j S. Cooper's First Lines of Surgery, 7th edit., p. 705. 
g Chelius's Surgery, South, vol. ii. p. 206. 32 
This should be attempted first by manipulation, accompanied, if need be, by 
the subcutaneous division of clearly recognized resisting structures. Failing 
in this, some one or more of the different appliances for exerting greater 
power, already described, may be adopted, never, however, carrying the efforts 
beyond the bounds of prudence. 
If, after these attempts, the surgeon fails to effect the restoration of the 
bone, there are still other resources at his command to remedy some of the 
inconveniences or disabilities connected with the displacement. Professor 
Edward Warren,* of Baltimore, in 1869, in the case of a female who suffered 
from the pressure of the head of the humerus on the axillary plexus of nerves, 
cut down upon the parts and excised the extremity of the bone by sawing 
through the surgical neck. 
As the evil consequence attending the malposition of the bone is not so 
much due to its contact with the nerves and vessels of the axilla as to the 
pressure exerted on these during the movements of the arm, Dr. Mears, of 
Philadelphia, in a case of old luxation, divided subcutaneously with an Adams 
saw the surgical neck of the humerus, with the effect of giving to his patient 
a useful and painless arm. 
During the winter of 1878, while making an effort to break up the ad- 
hesions of a luxation of the humerus in the person of an aged female, the 
bone snapped asunder at its surgical neck, with an audible noise. It oc- 
curred to me to establish in this case a false joint, by keeping up constant 
movements until the ends of the bone should have undergone those changes 
which would prevent their reunion. The result was highly satisfactory, as 
regards both the use of the arm and freedom from pain. 
In instances, therefore, of ancient luxations of the humerus, where the 
prospect of restoration is one of great uncertainty, and where the attempt 
at reduction is not unattended with danger, the patient may be greatly 
benefited by cither a subcutaneous section of the bone, as practiced by Dr. 
Mears, or by drilling it in the same locality, so as to render it sufficiently 
weak to admit of an easy fracture, in either case taking care to produce a 
pseudarthrosis by daily motion. 
Laceration of Vessels.-In the reduction of old luxations, aneurism, fatal 
hemorrhages, and extensive extravasations of blood have occurred from rup- 
ture of the principal vessels (generally the artery) of the part, as of the 
axillary in ancient dislocations of the humerus, and of the brachial in similar 
dislocations of the elbow. The treatment of such cases will be described 
under the head of Special Luxations. 
Laceration of Muscles.-Even the great pectoral muscle has been torn 
across in violent efforts to restore an old luxation of the shoulder, and in 
another case, already alluded to, that of Guerin, all the muscles connecting 
the forearm with the arm were severed. 
Laceration of Nerves.-Examples are not wanting of such an accident, 
even where portions of the brachial plexus have been torn by their roots 
from the spinal marrow. I doubt not that many of those cases in which 
the patient is not able, after reduction, to raise the arm towards the head, 
and in which the deltoid muscle becomes atrophied, are ascribable to some 
damage to the circumflex nerve, inflicted in efforts made to replace the bone. 
The consequences of such an injury are the loss of power and wasting of the 
muscles supplied by these nerves. 
Abscesses.-These may follow the disturbance of the parts in the vicinity 
of bone which has been long dislocated, and must be treated on the same 
principles as abscesses from other causes, by evacuating the pus, at the same 
time taking care not to injure the blood-vessels. 
DISLOCA TIONS. 
* Baltimore Medical Journal and Bulletin, Sept. 1871, p. 532. CONGENITAL LUXATIONS. 
33 
CONGENITAL LUXATIONS. 
Congenital luxations most generally affect the hip-joints, and are due to 
causes very imperfectly understood, but which are traumatic, nervous, or 
connected with an arrested development of the embryo. 
Traumatic.-The traumatic variety will include those which are supposed 
to result from an injury inflicted upon the abdomen of the mother, or from 
a contraction of the uterus on the foetus at a time when the limb is in some 
posture favorable to dislocation. If intra-uterine fractures occur in these 
ways, there is nothing incredible in luxations being determined by the same 
kind of violence. It is not improbable that some cases of so-called congen- 
ital dislocations have been produced by the accoucheur in forcible attempts 
at delivery. I once saw a case of luxated shoulder in a youth twelve years 
of age, which had escaped observation, and which, from the circumstances 
attending the case, had doubtless been caused in this way. 
Nervous.-It is reasonable to suppose that those central influences which 
are concerned in producing club-foot, either through cerebro-spinal irritation 
concentrated on certain groups of muscles, or from paralysis, may be equally 
efficient in causing the displacement of a joint. Such was the opinion of 
Chaussier, Guerin, Breschet, Carnochan, and others. 
Defects of Fcetal Development.-The defect may be partial or gen- 
eral. That is, it may be confined to the articulating cavity and the head of 
the bone, the former being very shallow and imperfect, and the latter small, 
flat, and deformed; or the vice may affect all the components of the joint, 
manifesting itself in distention of the ligaments, or their rupture, in an imper- 
fect development of the bones, the cavity of the one being very shallow, or 
filled up with a soft fibrous or fibro-adipose material, and the head of the other 
misshapen, dwarfed, and flattened, and occupying a new but imperfect cavity. 
These dislocations are sometimes associated with monstrosities, and are also 
seen in cases of idiocy. Palletta and Dupuytren were both earnest advo- 
cates of the theory of embryonic defects of organization as the cause of con- 
genital luxations. In these luxations the muscles also are very much changed 
both in structure and in form, being atrophied. 
Treatment.-These dislocations are generally irremediable, yet occasion- 
ally something can be done towards remedying the defects. 
Attempts may be made to restore the displacement by gradual and long- 
continued extension, applied either by elastic bands or by a weight suspended 
from the limb, as in fractures of the femur. If, after repeated attempts, the 
head of the bone cannot be thus conducted to its socket, and the obstacle to 
the reduction can be clearly referred to the resistance of a particular muscle, 
that resistance should be removed by subcutaneous section, after which the 
efforts to reduce may be renewed. Failing to bring the bone to its proper 
functional position, the next attempt should be, when the head of the bone is 
favorably situated, to establish a new socket, by carrying a well-padded strap 
around the pelvis and the two great trochanters of the femora, so as to fix the 
head of the bone firmly against the pelvic wall, and in this way to endeavor 
to produce what nature frequently does in old, unreduced luxations. As a 
necesssary preliminary to this measure, Guerin made a number of subcu- 
taneous scarifications through that part of the capsule between the head of 
the bone and the pelvic walls against which it rested, as well as through the 
other soft parts immediately around. 
The inflammatory consequence of such incisions is to surround the artic- 
ulating extremity with a mass of connective tissue, and in this way to moor 
it within very narrow limits, after which the work of forming the new cavity 
is commenced. 
In two cases of congenital dislocation of the hip I was able to give some 
relief by an apparatus which, while it pressed the thigh-bones against the 
sides of the pelvis, at the same time partially supported the weight of the 
VOL. II.-3 34 
DISLOCATIONS. 
body on the perineum, as is done by the perineal band attached to instru- 
ments worn for coxalgia. 
SPECIAL DISLOCATIONS. 
Dislocation of the Inferior Maxillary Bone. 
Dislocation of the inferior maxillary bone may be regarded as a compara- 
tively rare accident. Of 912 dislocations admitted into the Pennsylvania 
Hospital, only 9 were luxations of this articulation. Of this number 6 were 
males and 3 females, though generally the latter are in the majority. No 
case was noticed under twenty-five years of age, the largest number (5) 
occurring between twenty-five and thirty-five, and 1 at seventy-five years. 
Sir Astley Cooper has witnessed a single instance of the injury in a child. 
The absence of the alveolar processes in very young or very old inferior* 
maxillae, and the consequent obtuse angle between the body and the ramus 
of the bone, render dislocation of the temporo-maxillary articulation very 
improbable at the extremes of life. 
The dislocation may be bilateral, unilateral, or incomplete, or, as the latter is 
sometimes called, a subluxation. 
Causes.-The causes are predisposing and exciting. Among the predis- 
posing causes may be mentioned a shallow glenoid cavity, the articular emi- 
nences being unusually low. These latter ridges may be materially altered 
by dental irregularities. This is very evident in a skull in my possession, in 
which the eminence on one side is worn down obliquely, and to an extent 
which must have rendered the articulation quite insecure. Preternatural 
relaxation of the ligaments and weakness of the muscles of mastication are 
also predisposing causes, and are induced by anaemia and feeble conditions 
of the general health. 
The exciting causes are blows or falls upon the chin, gaping, biting upon 
hard substances, and even immoderate laughing. Instances of this disloca- 
tion are noticed by writers as having occurred under unusual circumstances. 
Sir Astley Cooper mentions one caused by an apple being forced between 
the maxillae. Dorsey gives the case of a virago who, in a paroxysm of rage, 
and while scolding her husband, luxated her jaw. Hamilton records a case 
in which the dislocation occurred while a dentist was taking the impression 
of the mouth preparatory to constructing a set of teeth. Several times has 
the accident been produced while the roots of teeth were being pried out of 
their sockets. The late Professor Gibson was in the habit of relating a case 
of displacement of the inferior maxilla which took place in the person of a 
man who was exceedingly penurious and close in all his business transac- 
tions. On one occasion, he fell and dislocated his jaw. A surgeon was imme- 
diately called in, who promptly reduced the displacement. The fee demanded 
for the operation was deemed by the patient unreasonable, and he objected 
to its payment. " Never mind," said the surgeon; " pay me what you please ; 
but in the mean time let me tell you a good joke." The joke proved so 
amusing that the patient burst into a hearty laugh, during which the con- 
dyles again slipped from the cavities. The aid of the surgeon was once 
more solicited, but this time he declined rendering the desired assistance 
until his fee had been paid in hand. 
Mechanism.-The exact manner in which dislocation of the lower jaw is 
accomplished has been the subject of considerable discussion by Nelaton, 
Malgaigne, Maisonneuve, Otto Weber, and others. I have many times pro- 
duced the luxations on preparations of the head, and am convinced that the 
process is a very simple one. When the inferior maxillary is strongly de- 
pressed the condyles move forward, carrying with them the interarticular 
cartilages, and rising on the eminent!® articulares. In this position of the 
bone the insertion of a part of the fibres of the masseter muscle is carried 
backward, and those fibres are consequently put upon the stretch. The DISLOCATION OF THE INFERIOR MAXILLARY BONE. 
35 
same is true of the anterior fibres of the temporal muscles. If, at this junc- 
ture, the depression of the jaw is slightly increased from any cause, the 
condyles will break through the front of the capsular ligament, and be sud- 
denly pulled over the articular eminences by the contraction of the external 
pterygoid muscles, assisted by the tense portions of the masseter and tem- 
poral muscles. The muscles of mastication are very irritable, are all sup- 
plied from the same trunk, viz., the motor branch of the fifth pair of nerves, 
and act very energetically upon the application of any stimulus. The con- 
dyles, once over the articular eminences, take their position directly in front 
of the latter, being drawn up towards the temporal fossae by the temporal, 
pterygoid, and masseter muscles. The coronoid process, in most instances, 
barely touches the malar bone, and the external lateral ligament is only 
partially torn. 
Bilateral Dislocation.-When both condyles are removed from their artic- 
ulating cavities, the front teeth of the maxillae will be found separated to 
the extent of an inch (the interval may be more or less); the mouth remains 
open; the dental arch of the lower jaw is in advance of that of the upper, 
giving to the chin an unduly prominent or elongated appearance; the artic- 
ulation is indistinct; the saliva dribbles from the mouth, in consequence 
of the pressure upon the parotid glands exciting increased secretion; the 
prominences of the condyles in front of the ear, which, when the bone is in 
Fig. 910. 
Fig. 911. 
Position of the lower jaw in bilateral dislocation. 
its natural position, can be distinctly 
felt, disappear, and in theii' place ap- 
pear depressions, while immediately be- 
hind the malar bone a slight elevation 
exists, caused by the coronoid process 
and the tendon of the temporal muscle. 
(Figs. 910 and 911.) The jaw is fixed, 
and the pain is usually severe, in consequence of pressure on branches be- 
longing to the sensitive part of the fifth pair of nerves. 
Unilateral Dislocation.-In this luxation only one condyle is displaced, in 
consequence of which the lower jaw is carried towards the opposite or unin- 
jured side, giving to the chin a twisted appearance. The incisor teeth of the 
lower jaw on the sound side are found external to those of the upper jaw, 
the maxillse are somewhat separated, and the mouth is partially open. In ad- 
dition to these signs, the jaw is fixed, and a depression will be found in front of 
the ear on the side of the displacement, as well as an unusual prominence 
of the condyle on the sound side. (Fig. 912.) It must be observed, however, 
that all of these distinctive characteristics of unilateral luxation are not 
always present, and, consequently, the injury may exist without its nature 
Bilateral dislocation of the lower jaw. 36 
DISLOCATIONS. 
being altogether clear. The fixed state of the maxilla and the depression 
in front of the ear will, however, serve to remove any doubt. 
Subluxation.-Under this term 
Sir Astley Cooper describes a fixed 
condition of the jaw, which he sup- 
posed was due to the interarticular 
cartilages slipping behind the con- 
dyles and locking them upon the 
articular eminences. The nature of 
this displacement has never been 
verified by dissection. Those who 
are the subjects of this luxation are 
generally young persons having a 
very feeble and relaxed muscular 
system, with little constitutional 
stamina. The symptoms of the 
disarrangement are a sudden im- 
mobility of the jaw, coming on 
while chewing or biting upon some 
hard substance, with a slight sepa- 
ration of the incisor teeth. 
DiagnosisThe only injury with 
which luxation of the lower jaw can 
be confounded is a fracture of the 
neck of the condyle. The distinc- 
tion can be established by the mo- 
bility of the jaw and the presence 
of the condyloid prominence in its 
functional position below the zygomatic line,-signs which exist in the latter 
injury. It can be established also by the chin, in fracture, falling to the 
injured side, while in dislocation of one condyle the chin inclines to the oppo- 
site side. Trismus and paralysis, except in the rigidity of the jaws in the 
first, and the obliquity of the face in the second, have so few points of re- 
semblance that it is very improbable they would ever be confounded with 
luxation of the jaw. 
Prognosis.-The reduction of a dislocated jaw is usually easily accom- 
plished ; and though the articulation is rendered less secure by the occurrence 
of the displacement, yet its movements are not materially affected. Even in 
instances of non-reduction, the deformity and the disability immediately fol- 
lowing the accident measurably disappear in time, and a reasonable degree 
of movement and of power is acquired over the jaw. Quite a number of old 
dislocations of the inferior maxilla have been successfully treated. Physick 
restored one nine weeks after its occurrence; Pollock, one after the lapse of 
four months; Donavan, one ninety days following the injury; and Demarquay 
and Stromeyer, each one, the first eighty-three, and the last thirty-five, days 
succeeding the dislocation. 
Treatment.-The patient being seated on a low chair or stool, an assistant 
standing behind to support the head, the surgeon takes his place in front, 
and, having the thumbs well protected by a shield of leather or by a linen 
handkerchief, passes them back until they rest on the molar teeth on each 
side, with the finger planted along the outside of the base of the jaw. (Fig. 
913.) This is done in order to disengage the condyles from their unnatural 
position within the zygomatic arch, thereby overcoming the contraction of 
the masseter, the anterior part of the temporal, and the internal pterygoid 
muscles. Then, by elevating with the fingers the anterior portion of the 
bone, the condyles will be drawn into position by the posterior portions of 
the temporal and the deep masseter muscles. The return of the bone into 
place is announced by an audible sound, and it occurs with such suddenness 
Fig. 912. 
Unilateral dislocation of the lower jaw. NOISY MOVEMENTS OF THE TEMPORO-MAXILLARY JOINTS. 
37 
and force that, unless the operator is careful to shift his thumbs over to the 
sides of the gums, they may be severely contused between the teeth. 
In luxations of long standing, if 
the thumbs are not found to be 
sufficiently powerful to effect the 
necessary depression, two wooden 
levers should be employed, counter- 
pressure being at the same time 
applied beneath the chin. Should 
any unusual resistance be encoun- 
tered, oi' if the patient is very sen- 
sitive to pain, the reduction will be 
greatly facilitated by administering 
ether. 
Other methods have been em- 
ployed to restore these displace- 
ments, which, in most cases, are 
neither so effective nor so simple 
as the one described. Sir Astley 
Cooper thrust a cork between the 
molars on each side, and then for- 
cibly raised the chin. M. Nelaton, not deeming it essential to raise the 
chin, and believing that the chief resistance to be overcome was that of the 
lock between the coronoid process and the malar bone, after directing the 
jaws to be widely opened, planted his thumbs against the coronoid processes, 
either within or without the mouth, and pressed them forcibly downward 
and backward. It was in this way that this distinguished surgeon succeeded 
in restoring a luxation of the temporo-maxillary articulation which had suc- 
cessfully resisted repeated attempts made by others at reduction. 
After the bone has been replaced, the jaw 
should be supported for eight or ten days by a 
Barton bandage or by the sling of the chin. 
(Fig. 914.) 
For restoring a unilateral dislocation of the jaw, 
the same rules are to be observed as are appli- 
cable to the bilateral displacement, only applying 
the force to one side instead of to both. 
The subluxation is easily corrected by intro- 
ducing a case-knife between the teeth and prying 
the jaws apart. In this way a subluxation was 
immediately reduced by a medical friend after 
having passed unrecognized for four weeks. 
The plan of Nelaton for the reposition of bilat- 
eral luxations, by pressing the coronoid process 
downward and backward, may also be employed 
with success. 
Noisy Movements of the Temporo-Maxillary Joints.-This defect is a 
very common one, and is a source not only of mortification to the patient, but 
of considerable annoyance to persons who may be near. It consists of a 
snapping sound which is heard during the movements of the jaw in chewing. 
It is caused by the condyles mounting the articular eminences when the jaw 
is depressed, and then suddenly slipping back during its elevation. It is 
always an evidence of a lack of tonicity in the muscles of mastication, the 
relaxation of which causes the temporo-maxillary ligaments to become elon- 
gated, and in this way allows the joint surfaces to fall apart. The local dif- 
ficulty is only a symptom of general feeble health, and is best corrected by 
the administration of quinine, iron, and strychnia, and a resort to good food, 
cold bathing, electricity, and a life in the open air. Both the vice of subluxa- 
tion and that of noisy movements may degenerate into spontaneous luxation, 
Fig. 913. 
Reduciug a dislocated lower jaw. 
Fig. 914. 
Dressing after reduction of the lower jaw. 38 
DISLOCATIONS. 
in which one or both condyles slip out of the glenoid cavities in the most 
unexpected manner. 
When this condition is threatened, in addition to the treatment already 
prescribed, the jaw should be protected by a sling of the chin, fastened with 
tapes passed over the head. 
Cramp of the Jaw.-After gaping, the lower jaw is sometimes prevented 
from being closed against the upper one by a spasmodic contraction of the 
anterior belly of the digastric muscle, which can be felt beneath the chin as 
a hard, painful ridge. It is possible that this slightly-depressed state of the 
aw may occasionally be induced by the temporary arrest of the tendon of 
the same muscle, in the pulley by which it is looped to the hyoid bone. Most 
persons have at some period in their lives experienced this painful condition. 
It is probably the same affection as that which was described by Benevoli, 
and noticed by Hamilton in his work on " Fractures and Dislocations;" though 
I have never witnessed the swelling of the temporal muscles described by 
the Italian writer. 
The spasm is easily removed by friction with the finger over the rigid 
muscle. The disturbance is generally limited to a single muscle. 
Congenital dislocations of the inferior maxillary bone are exceedingly rare. 
A very remarkable instance of this kind has been recorded by Mr. R. W. 
Smith, in which the dissection showed a very imperfect development of all 
the components of the joint on the affected side, including bones, interartic- 
ular cartilages, ligaments, and muscles. 
The usual signs of unilateral or bilateral luxation are absent in this class 
of dislocations; but there is, nevertheless, a singulai' absence of facial sym- 
metry, the face being rotund on the sound side and hollow on the affected 
side, giving rise to a marked deformity of the features. 
DISLOCATIONS OF THE RIBS AND THE COSTAL CARTILAGES. 
Costo-Vertebral Dislocations. 
The ribs, with two exceptions, articulate posteriorly with the bodies and 
the transverse processes of the vertebrae, and anteriorly with the costo-sternal 
cartilages. The depth of the vertebral extremity of the ribs, their firm artic- 
ulations, and the protection they derive from their position under a consider- 
able mass of muscular tissue, render a dislocation in this locality extremely 
improbable. The possibility of such a displacement, however, has been 
certainly established. 
Mr. Poland, in his article on injuries of the chest, has collected together 
nine cases of costo-vertebral dislocation. In seven of these the diagnosis 
was verified by post-mortem examinations. The dislocated ribs were, in one 
case, the twelfth on each side, and the eleventh on the left side. In another 
case, it was the fourth left rib. In the third, two ribs were displaced, either 
the sixth and seventh, or the seventh and eighth. In a fourth, the tenth rib 
was completely luxated, and the eleventh partly so. In a fifth case, the two 
last ribs on the left side were displaced; and in two other instances the 
seventh rib was dislocated. 
In a man who had received a severe railroad injury, and who died from 
laceration of the lung, I found two ribs detached from their vertebral artic- 
ulations, and each of them was also broken. 
In three of Poland's collections the dislocation was accompanied either by 
fracture of some of the ribs or by other injuries. 
There are no signs characteristic of a costo-vertebral dislocation. In the 
observed cases, the only symptoms present were those of severe contusion, 
and, in one instance, of an indentation in the ribs supposed to be displaced. DISLOCATION OF THE BONES OF THE STERNUM. 
39 
The treatment in a case apparently of this nature will not differ from the 
treatment proper in fracture of the ribs. 
Costo-Chondral and Chondro-Sternal Dislocations. 
Dislocations of the anterior extremities of the ribs from their cartilages 
are also very uncommon injuries, quite as rare as those met with at the 
costo-vertebral articulation; and the same may be said of chondro-sternal 
luxations. Mr. Poland has only been able to collect four cases of the former 
and five cases of the latter displacement. Hamilton records one,-a dislo- 
cation of the fourth chondro-sternal cartilage,-which was under the care 
of Dr. Flagg, of St. Paul, Minnesota, and which is not included in Poland's 
table. 
In a lad ten years of age, whom I saw with Professor Penrose, several of 
the true ribs had been disconnected from their cartilages. The boy had sus- 
tained a number of fractures in different parts of the skeleton, and was 
paralyzed in the lower extremities. Professor Gross has met with a number 
of costo-sternal and chondro-sternal dislocations. 
The signs of these displacements are pain, a preternatural prominence in 
the position of the displaced rib or cartilage, undue mobility, crepitus, and 
sometimes a disturbed respiration. 
The treatment consists in restoring the displacement by drawing the 
shoulder backward, so as to put the great pectoral muscle on the injured 
side upon the stretch, at the same time extending the trunk. If this does 
not succeed, ether should be administered, in order that the patient may have 
the benefit of the long inspirations usually induced by this agent, and which, 
fully dilating the chest, favor the reduction. 
After the reduction, it will be necessary to surround the thorax with a 
broad bandage. 
The violence which causes these dislocations gives rise to very serious chest 
complications, which will demand the attention of the surgeon. 
The cartilages belonging to the sixth, seventh, and eighth ribs have opposed 
articular surfaces, connected together by capsular ligaments. These joints 
have in a very few (3) instances been displaced. 
In one of these cases the luxation occurred during the struggle consequent 
upon a fall backward from a chair. 
A depression corresponding to the displaced cartilage and an unusual 
prominence of the one above will indicate the nature of the injury. 
The reduction will require that the displaced cartilage be liberated from its 
position beneath the one above, which can be effected by pressing the latter 
upward and backward. After the luxation is restored, a compress should 
be applied over the articulation, and the chest enveloped in a broad bandage, 
or a few strips of adhesive plaster applied over the seat of the injury and for 
some distance above and below it. 
Chondral Dislocations. 
Dislocation of the Bones of the Sternum. 
Dislocation, of the bones of the sternum is the result of such extraordinary 
violence that the accident is frequently followed by death. Malgaigne gives 
ten cases of traumatic dislocation of the sternum. The patients were all 
males, five of whom died from the injury. Dr. John Brinton, of Philadel- 
phia, has brought together and analyzed thirteen cases, one of which oc- 
curred in his own practice. Of these, seven died and six recovered. The 
luxation takes place between the manubrium and the body. It is produced 
by direct force, or by extreme flexion of the body. 
The displacement will be determined by the manner in which the separa- 40 
DISLOCATIONS. 
tion is brought about. When the determining force is received upon the 
body of the sternum, the latter will be driven beneath the manubrium; when 
caused by strong flexion of the spine, the first piece will be carried in front 
of the second. 
Poland says that several cases of this luxation have been seen during the 
past thirty years at Guy's Hospital. In none of these could reduction be 
accomplished; but when the complications were not too serious, the patients 
generally did well. 
The same author has tabulated 14 cases of this dislocation, with 6 deaths, 
5 cures, and in 3 the event was unknown. 
The signs of the dislocation will be evident, as the parts affected are 
accessible both to the eye and to the touch. 
Treatment.-Although, in most instances, the reposition cannot be effected, 
yet no case should be allowed to pass without an attempt to restore the bones 
to their proper position. A pillow should be rolled into a cylinder and placed 
beneath the trunk so as to extend the body, while the head is at the same 
time carried well back; while in this position traction or pressure should be 
made upon the luxated bone. An anaesthetic may also prove a useful 
adjuvant to these measures. 
If successful in adjusting the bones, a bandage should next be carried 
around the chest, to give greater security to the parts. The severe concus- 
sion often sustained by the thoracic contents in these injuries of the sternum 
and of the cartilages will demand attention. Hot flaxseed-meal poultices ap- 
plied over the front of the chest, and renewed every six hours, prove of the 
greatest value in preventing or resolving congestion of the viscera of the 
chest. And when there is much pain, opium in some form should be admin- 
istered. If, notwithstanding these measures, inflammatory complications 
arise, they must be combated by the local abstraction of blood and by 
moderate purgation; or, when dyspnoea and pain are urgent, by general 
blood-letting. 
Dislocation of the Ensiform Cartilage. 
Malgaigne has collected two cases of dislocation of the ensiform cartilage. 
In both the displacement was caused by force directly applied to the epigas- 
trium ; and in both the injury was followed by severe pain in the region of 
the stomach, and by difficult respiration and vomiting, which were only re- 
moved by the reduction of the cartilage. This was effected, in one of the 
cases, by pressing the finger beneath the cartilage and raising it into position. 
In the other case, reduction was effected by dividing the overlying tissues, 
including the peritoneum, along the side of the cartilage, and then hooking 
it into place. 
The dyspnoea attending this accident must be due, I presume, to irritation 
of one or both of the phrenic nerves. 
DISLOCATIONS OF THE VERTEBRAS. 
Aside from positive demonstration by dissection, it would seem almost im- 
possible that the pieces of a structure like the spinal column, bound together 
by numerous articulations and powerful ligaments and cartilages, could be 
disjoined by any force short of that which would work complete disorganiza- 
tion. Abernethy denied the possibility of such a dislocation. But, though 
this accident is exceedingly uncommon, a sufficient number of cases have 
been observed to establish the existence of this injury beyond a shadow of 
doubt. 
These dislocations are often conjoined with fracture. The fatality attend- 
ing them is almost universal,-a result which might be anticipated from the 
damage which must, in such luxations, almost inevitably be inflicted upon 
the spinal cord. 
In fractures of the spine, the fragments are frequently only slightly dis- DISLOCATIONS OF THE CERVICAL VERTEBRAE. 
41 
placed, and the spinal marrow may escape any serious lesions, other than 
those which may ensue from inflammatory changes. But in dislocation Ave 
rarely find so favorable a disposition of the displaced vertebrae. 
These dislocations may be arranged, according to the anatomical divisions 
of the spine, into those of the cervical and those of the dorsal vertebrae. 
I am not aware that any well-authenticated instance of an uncomplicated 
dislocation of a lumbar vertebra has been met with. 
Dislocations of the Cervical Vertebrae. 
The cervical region of the spine, in consequence of the degree of movement 
existing between its components, and also the superficial character of the 
articulating processes, furnishes the largest number of vertebral dislocations. 
The collections of Schranth, Malgaigne, and Bryant comprise in the aggre- 
gate 80 cases of cervical luxation, while a considerable number may be found 
scattered among various medical journals. Uncomplicated dislocations of 
the cervical vertebrae form a large percentage of the lesions affecting the 
bones of this region. 
The region embraced between the fourth and sixth cervical vertebras, in- 
clusive, seems to be exceptionally vulnerable, as will appear from the cases 
which I tabulate below. All those marked with an asterisk were verified 
by a post-mortem examination. 
Table of Dislocations of Cervical Vertebrce. 
Name of Medical 
Attendant. 
Age. 
Sex. 
Cervical Ver- 
tebra. 
Treat- 
ment. 
Result. 
Authority. 
Daniel Ayres. 
Adult. 
Male. 
5th bilateral. 
Reduced. 
Recovered. 
New York Jour. Med., vol. ii. p. 
9, 3d Series. 
W. W. Ryer. 
Girl. 
4th. 
<c 
C< 
Pacific Med. and Surgical Jour., 
W. II. White. 
Boy. 
5th bilateral. 
Cl 
44 
Sept. 1858. 
Boston Med. and Surgical Jour., 
vol. v. p. 174. 
D. W. Cheever. 
Adult. 
Male. 
5th and 6th. 
Died in 50 
Boston Med. and Surgical Jour., 
hours. 
June number, p. 75. 
Dr. Rogers.* 
Female. 
5 th. 
New York Med. Record, vol. iii. 
p. 478. 
W. H. Farrington.* 
R. J. Farquharsen.* 
Adult. 
ll 
ll 
ll 
6th. 
4 th. 
Died 6th 
day. 
Died in 25 
hours. 
Phila. Medical Times, vol. iv. p. 
215. 
American Jour. Med. Sciences, 
vol. Ixvi. p. 281. 
Robert Reyburn.* 
ll 
Male. 
5th unilateral. 
Reduced. 
Died in 15 
American Jour. Med. Sciences, 
W. G. Clark* 
ll 
ll 
5th and 6th. 
days. 
Died in 36 
vol. Ixii. p. 110. 
American Jour. Med. Sciences, 
hours. 
vol. xxvi. p. 85. 
Dr. Thaxter.* 
14 
ll 
5 th. 
Died 4th 
Boston Med. and Surgical Jour., 
Dr. Gay.* 
Dr. Jackson.* 
ll 
ii 
ll 
ll 
5th. 
5th and 6th. 
day. 
Died 11th 
day. 
Died 3d 
vol. x. p. 349. 
Boston Med. and Surgical Jour., 
vol. x. p. 275. 
Boston Med. and Surgical Jour., 
E. K. Sanborn.* 
ll 
ll 
5th. 
day. 
Died 8th 
vol. Ixv. p. 120 (Old Series). 
Boston Med. and Surgical Jour., 
E. K. Sanborn.* 
5th and 6th. 
day. 
Died 3d 
vol. xlv. p. 69. 
Boston Med. and Surgical Jour., 
G. W. Norris.* 
Adult. 
Male. 
5th. 
day. 
Died 3d 
vol. xlv. p. 69. 
American Jour. Med. Sciences, 
Lente. 
Lente. 
5th. 
5th. 
day. 
Died 5th 
day. 
Died in 2 
vol. i. p. 336 (New Series). 
New York Jour. Med., Muy, 1850, 
p. 284. 
New York Jour. Med. May, 1850, 
hours. 
p. 397. 
W. II. Horner. 
Dr. Shuck. 
Adult. 
ll 
Male. 
Cl 
4th. 
Reduced. 
Recovered. 
American Jour. Med. Sciences, 
April, 1843. 
American Jour. Med. Sciences, 
Dr. E. Maxson. 
Child. 
5th and 6th. 
cc 
44 
vol. ii., July, 1841, p. 207. 
Buffalo Medical Jour., Jan. 1857, 
p. 479. 
Dr. Hickeman. 
4th and 5th. 
14 
44 
Ohio Med. and Surg. Jour., 1854- 
57, vol. vii. p. 345. 
Schranth. 
Mr. Vrignonneau. 
4th. 
5th. 
44 
44 
44 
44 
American Jour. Med. Sciences, 
May, 1848. 
Malgaigne, Trait. Disloc., p. 363. 
Dr. Purple. 
5th and 6th. 
New York Jour. Med., May, 1853, 
p. 319. 42 
DISLOCATIONS. 
These dislocations may be complete or incomplete. They may take place in 
a forward or in a backward direction. When the articulating processes of 
one side are displaced, the luxation is lateral. When those of both sides are 
displaced, the luxation is bilateral. In treating of these dislocations, they 
may be arranged into those which take place below, and those which take 
place above, the second cervical vertebra. 
Dislocations below the Second Cervical Vertebra. 
A luxation may occui' at any of the articulations between the second cer- 
vical and the first dorsal vertebra. The direction of the displacement is 
generally forward; that is, the vertebra below the one displaced remains 
fixed, while all the vertebrae above are carried in an anterior direction. (See 
Figs. 915 and 916.) 
Fig. 915. 
FlG. 916. 
Forward dislocation between the fourth and fifth cer- 
vical vertebra). Front view. 
Side view of the same, being a vertical section, exposing 
the injury to the spinal cord. 
The manner in which these luxations occur would seem to show that, for 
their production, it is necessary that great violence should be applied either 
to the head while it is bent forward towards the breast, or directly to the 
back of the neck. In the unilateral or one-sided displacement the force is 
supposed to act more on one side-the affected side-than on the other. 
Or this luxation may result from the spine being violently twisted. 
In a complete luxation, the ligaments uniting the articular processes are 
torn, the lower processes of the upper or displaced vertebra being placed in 
front of, oi' behind, the upper processes of the lower or stationary vertebra, 
as the ease may be. The posterior common vertebral ligament gives way, 
and the intervertebral cartilage is ruptured. The anterior common ligament 
has been found to retain its continuity, though detached for some distance 
both above and below the luxation. In addition to these lesions, the cord 
may be contused, crushed, or even severed. Blood is also extravasated both 
within and without the spinal canal. 
Symptoms.-Though in many instances there must remain some doubt as 
to the exact nature of the injury, yet in well-marked cases of this luxation 
the head assumes a certain position, dependent upon the direction of the dis- 
placement; that is, it will be flexed upon the breast when the luxation is 
backward, extended or carried backward when the luxation is forward, 
and turned to one side or the other when it is a lateral luxation. A break 
in the line of the spinous processes may also be detected, the luxated vertebra 
and all above it being found either in front of, behind, or to one side of those 
below the seat of injury. The same want of regularity which is noticed in 0 CCIPITO-A TL 01D DISL 0 CA TIONS. 
43 
the position of the spinous processes may be seen to exist to some extent 
also in the anterior surfaces of the bodies of the vertebra), by examining the 
posterior wall of the pharynx. 
As in fracture, so in dislocation of the cervical vertebrae, paralysis, more 
or less complete, follows the injury, affecting all the parts below the seat of 
displacement. Death, after a lesion of this nature, may follow almost in- 
stantly, especially w'hen the luxation is above the origin of the phrenic 
nerves; or it may be delayed for a few days, rarely exceeding two. Of 11 
cases which appear in the table and were verified by post-mortem examina- 
tion, all died at periods ranging from twenty-five hours to eleven days, except 
in a single instance, where the patient lingered fifteen days. 
Treatment.-There has been much diversity of opinion as to the pro- 
priety of making any attempts to reduce dislocated vertebree. But the 
number of instances in which efforts of this kind have proved successful has 
multiplied to a degree which now leaves no doubt about the propriety of sur- 
gical interference. Of the 9 cases noted in the table, which were believed to 
have been genuine examples of dislocation, in which reduction was practiced, 
all save one recovered; while in the 15 cases in which no efforts at reduction 
were made, all died except two, viz., those recorded by Purple and Horner. 
It is worthy of note that in no case of luxation below the second cervical 
vertebra have the vertebral vessels been injured. 
In a complete dislocation of the vertebra, the reduction is effected by 
placing the patient on a firm table in the recumbent position, and, after 
passing folded sheets obliquely across the shoulders and securing their ends 
to the table, making extension with the hands placed under the chin and 
behind the occiput, varying the direction of the head according to the dis- 
placement. 
When the prominence of the displaced vertebra can be felt through the 
pharynx, the reposition can be facilitated by making pressure, with the finger 
introduced through the mouth, against the projection, but at the same time 
keeping up the traction in the head. In like manner pressure should also 
be exerted upon any posterior prominence which can be discerned when the 
luxation is backward. 
When the displacement is unilateral, in addition to the extension and 
counter-extension, the inclination of the head towards the sound side should 
be first slightly increased, in order to disentangle completely the luxated 
processes. Afterwards the head should be rotated towards the injured side. 
The use of an anaesthetic will materially contribute to the success of any 
efforts made with a view to reduction. 
Dislocations above the Second Cervical Vertebra. 
The dislocations which occur above the second cervical vertebra are the 
occipito-atloid and the atlo-axoid. 
In the three dislocations of the occipito-atloidean articulation which have 
been reported, the injury was produced by violence applied to the back of 
the head or neck. In the first case (that given by M. Lassus), a bale of hay 
fell from a height, striking upon the back of the neck a man whose head, at 
the time of the accident, was bent over upon the breast. In the second case, 
recorded by M. Palletta,* the dislocation was the result of a fall, in which 
the back of the man's head, most probably, first struck the ground. In the 
third (M. Bouisson's case), the patient was a boy, w;ho bad been crushed under 
a wagon. In each instance the injury proved fatal. 
The lesions in all three of these cases were different. In the first, there 
was an almost complete separation of the condyles of the occipital bone from 
Occipito-Atloid Dislocations. 
* Cooper's Surgical Dictionary. 44 
DISLOCATIONS. 
the cup-shaped cavities of the atlas, with laceration of the vertebral vessels. 
In the second, the atlas, though displaced, was not wholly separated from the 
occipital bone. And in the third, the dislocation was unilateral, the right half 
of the posterior arch of the atlas being forced against the medulla oblongata. 
Atlo-Axoid Dislocations. 
The peculiar nature of the articulation between the atlas and the axis, ad- 
mitting of extensive rotation, renders it particularly liable to injury from 
violent or extreme twists of the head, or from similar movements of the body 
wThen the bead is fixed. Luxation of the atlo-axoid articulation may take 
place in several ways. When the odontoid process is broken, the atlas may 
slide backward from the axis, carrying with it the process, and crushing the 
upper portion of the spinal cord. Or the odontoid ligament may be rup- 
tured, together with some fibres of its transverse portion,-a lesion which 
will allow the odontoid process of the axis to slip beneath it, even though 
the transverse ligament may remain unbroken. Again, the atlas may be 
rotated upon the axis to a degree which will cause rupture of the articular 
ligaments and a displacement in which the atlas will rest obliquely across 
the axis, the lower articulating process of the atlas being in front of, and the 
other atloidean process behind, the axoid process. And, lastly, the dislocation 
may be limited to the articulating processes of one side. Mr. Cruikshank* 
and Dr. have each given an instance of spontaneous luxation of 
the processus dentatus. 
Atlo-axoid displacements are the result of falls upon the head, strokes or 
blows upon the back of the neck, sudden and extreme twists of the head, 
or twists of the body when the head is held motionless. It wTas probably in 
this last-mentioned way that the axis was displaced from the atlas, causing 
the instantaneous death of a child while being raised by the head and 
struggling to release itself, in a case mentioned by Petit. 
There is also a form of displacement which is due to caries, and is now and 
then met with among scrofulous children. 
Symptoms.-The symptoms of an atlo-axoid luxation must necessarily be 
very vague and uncertain. Should the head be found twisted to one side and 
incapable of rotation, with a bent state of the neck, and it were known that a 
sufficient cause of luxation had been applied, there would be presumptive 
evidence of a unilateral displacement, provided, however, no deformity could 
be felt at a lower part of the cervical region. 
The prognosis in injuries of this nature must be exceedingly unfavorable, 
in consequence of the paralysis following the damage done to the medulla or 
to the cord. Cases, however, are recorded in which the displacement was 
reduced and recovery followed. One of these was under the care of Desault. 
The patient was a child, who is supposed to have produced the luxation 
while resting on the head with the feet in the air,-a practice very common 
among young lads. Suddenly the head became twisted to one side and fixed, 
severe pain and loss of power ensuing. The reduction was accomplished by 
fixing the body, making gradual traction of the head, and then turning the 
latter in a direction opposite to that of the deformity, when the symptoms of 
the dislocation immediately disappeared. Malgaigne gives two cases of a 
similar displacement, one of which was observed by his father and the other 
by M. Ehrlich; both having been restored by extension, counter-extension, 
and rotation. Whether these were really atlo-axoid dislocations, or disloca- 
tions lower down, it is impossible to determine. 
Treatment.-As some uncertainty must necessarily attend the diagnosis 
of all such injuries, and as it is impossible to determine the complications 
which may exist, the greatest care will be necessary whenever an attempt is 
made to correct the supposed displacement. For an ill-advised movement 
® London Medical Gazette, vol. iii.; Cooper's Surgical Dictionary. 
f Edinburgh Medical and Surgical Journal, vol. xlii. p. 79, Cooper's Surg. Dictionary. DISLOCATIONS OF THE DORSAL VERTEBRAE. 
45 
may inflict more serious damage to the cord than that occasioned by the injury 
itself. 
That an effort at adjustment should be made admits of no discussion, as 
it is only by rectifying the evil that we can hope to save the patient's life. 
The clearest possible conception of the injury, however, should be obtained 
before any movements are made with a view to the reposition of the dis- 
placed vertebra. 
Only general rules can be laid down to guide the surgeon in the reduction. 
The details applicable to particular cases must be left to his good sense. 
1. The extension should be made in the line of the spinal column, and it 
should be exerted in a steady, gradual manner. 
2. The counter-extension should be made from the shoulders: it is best 
applied by sheets passed over the shoulders, crossed in front and behind, and 
secured io the table upon which the patient lies. Or it may be made by 
the feet of the operator, planted against the summit of the shoulders, at the 
same time that he applies traction from the head with the hands. When 
the attempt to reduce is made with the patient in the sitting posture on the 
floor, the practitioner can fix the trunk by resting his knees on the shoulders 
of the patient. 
3. Pressure and counter-pressure will materially assist in the work of 
replacement whenever a prominence denotive of the luxated piece can be 
discovered. The pressure should be applied over the salient body, and the 
counter-pressure against the stable part of the spinal column. 
4. The head must be carried forward or backward, or rotated to one side 
or the other, according to the kind of dislocation. 
If the attempts at reposition are crowned with success, the patient should 
be placed on a hard bed, with the head resting on a low, soft pillow and 
supported so as to prevent its falling to either side. The state of the bladder 
and of the bowels must not be overlooked. 
Dislocations of the Dorsal Vertebrae. 
The secure manner in which the dorsal vertebrae are locked together, the 
great strength of the intervertebral cartilages and ligaments, and the extent 
of their articulating surfaces, combine to render uncomplicated luxation of 
these bones a matter of great difficulty. Generally their displacement is 
associated with a fracture. This was the condition in most of the 13 cases 
collected by Malgaigne, the verity of which was established by dissection 
after death. 
The vertebra? occupying the lower part of the dorsal region arc those 
which suffer most, as the flexibility of the spine in this locality renders it 
more vulnerable than at any point below the neck. This is well illustrated 
by the fact that of the 13 dislocations alluded to above, 7 occurred between 
the ninth dorsal and the first lumbar vertebra. 
The displacement may be forward, backward, or lateral. 
These injuries are usually caused by extreme flexion of the spine, con- 
joined with the direct application of force. 
The signs of the dislocation cannot be distinguished from those of fracture, 
being those of paralysis of the lower extremities, bladder, and rectum. 
Treatment.-The chief indications are to provide for the vesical and rectal 
incontinence, and to prevent the occurrence of bed-sores. 
At first it may be necessary to employ the catheter. But in a short time 
the urine will dribble away involuntarily. It should then be received into a 
urinal, or a bottle, so placed that the bed may be kept unsoiled. As, how- 
ever, a certain amount of the urine-that in the most dependent part of the 
bladder-does not escape, catheterization will be required at least once in 
three days. 
The evacuations can be received on a pledget of oakum. 46 
DISLOCATIONS. 
The water-bed, when it can be procured, will be the best protection against 
bed-sores. 
DISLOCATIONS OF THE BONES OF THE UPPER EXTREMITY. 
Dislocations of the bones of the upper extremity may be divided into those 
of the shoulder, the arm, the forearm, and the hand. 
Dislocations of the Shoulder. 
Dislocations of the shoulder include those of the clavicle and the scapula. 
The latter are often termed dislocations of the clavicle at the acromial end. 
Dislocations of the Clavicle.-In 912 dislocations admitted into the Penn- 
sylvania Hospital, 74 belonged to the clavicle, including, of course, those 
located at both ends of the bone. According to Flower, the relative fre- 
quency of these luxations is 3.10 per cent. Males are much more liable to 
this accident than females,-in about the proportion of four to one. The 
sterno-clavicular displacement, as compared with that of the scapula, is quite 
uncommon. In 50 cases observed by Hamilton, 41 were situated at the 
acromio-clavicular articulation, and only 9 at the sterno-clavicular. In 15 
cases in which the location of the luxation is noticed in Alison's table,* 12 
were at the sternal and 3 at the scapular extremity of the bone. 
The clavicular articulation is formed between the end of the clavicle and 
the superior angle of the sternum. Between the two is an interarticular 
cartilage attached below to the first costal cartilage and to the clavicle above. 
The joint is surrounded by a capsular ligament, strengthened anteriorly and 
posteriorly by the anterior and posterior sterno-clavicular ligaments. Be- 
tween the first costal cartilage and the under surface of the clavicle is the 
costo-clavicular or rhomboid ligament. And connecting the ends of the 
two bones is the interclavicular ligament. 
(Fig. 917.) 
Dislocations of the clavicle (sterno-cla- 
vicular) may occur in three directions,- 
forward, backward, and upward. The dis- 
placement downward is prevented by the 
cartilage of the first rib, on which the 
bone rests. 
Dislocation Forward. - The most fre- 
quent luxation is that forward; and this 
may be complete or incomplete. 
In the complete variety the capsular, 
anterior and posterior sterno-clavicular, 
and rhomboid ligaments are torn. The interarticular cartilage may ac- 
company the clavicle, or it may still adhere to the articular fossa. The 
end of the bone takes a position in front of and near to the upper extremity 
of the sternum. (Fig. 918.) In rare instances it has been seen considerably 
lower. 
When the luxation is incomplete, the capsular ligament is only partially 
torn, together with some fibres of the anterior sterno-clavicular ligament. 
Causes.-Any force of sufficient intensity acting on the outside of the 
shoulder (especially when it is drawn back), or against its anterior aspect, 
may cause this displacement. 
Symptoms.-The signs of a complete luxation are the presence of a hard 
swelling lying in front of the upper part of the sternum, immediately under 
the skin, a tense ridge, answering to the clavicular origin of the sterno- 
cleido-mastoid muscle, and with these a diminished space between the aero- 
Fig. 917. 
Sternoclavicular, costoclavicular, and inter- 
clavicular ligaments. 
* Manuscript Table of Dislocations at the Pennsylvania Hospital. DISLOCATIONS OF THE SHOULDER. 
47 
process of the scapula and the sternum. (Fig. 919.) The movements 
•f the arm are generally restricted, 
md cannot be made without pain 
ieing experienced at the seat of in- 
ury; and the head, as in fracture of 
he clavicle, is usually inclined to- 
vards the shoulder of the affected 
Fig. 919. 
Fig. 918. 
Position of the clavicle in anterior disloca- 
tion at the sternal extremity. 
Deformity following anterior luxation of the 
sternal end of the clavicle. 
In the incomplete luxation the bone does not wholly leave its articulating 
cavity, inasmuch as the capsular ligament is only partially ruptured. The 
anterior prominence is, consequently, less marked than in the complete form 
of the injury, and is on a higher level than in the latter luxation. 
Treatment.-Generally there is not much difficulty in reducing the lux- 
ation. This is most conveniently done by putting the patient on a stool oi' 
chair, and directing an assistant, after placing the knee between the scapula?, 
to draw the shoulders strongly backward, the surgeon at the same time 
pressing the displaced extremity into place. 
If this method fails, a large woolen ball, or a 
pad fashioned out of any convenient material, 
should be placed in the axilla as a fulcrum. And 
while, with one hand, the surgeon, using the arm 
as a lever, grasps it at the elbow, pressing the lat- 
ter to the side, and at the same time carrying the 
shoulder upward and backward, with the other 
hand he manipulates the bone into position. The 
difficulty, however, consists in- keeping the bone 
in position,-a difficulty which thus far has proved 
insurmountable, in consequence of the weight and 
mobility of the shoulder and the shallowness of 
the articulating cavity on the sternum. 
The dressings which have been employed for 
this purpose are the Desault and the Fox appa- 
ratus, used in the treatment of fractured clavicle; 
the adhesive plaster dressing, used for the treat- 
ment of the same injury; the posterior eight roller, 
and the Velpeau bandage. All appliances which 
draw the shoulders backward tend to force the sternal extremity of the 
clavicle against the anterior part of the ligament, and thus, unhappily, to 
facilitate rather than restrain the reproduction of the dislocation. All that 
can be hoped for is to maintain the bone approximately in position until such 
adhesions have been established as will give a certain degree of fixedness to 
its extremity. For this purpose the Velpeau dressing (Fig. 920)-allowing, 
Fig. 920. 
Velpeau dressing for luxation of the 
sternal end of the clavicle. 48 
DISLOCA TIONS. 
as it does, the shoulder to come forward, and at the same time securely 
immobilizing both it and the arm-will be found to possess advantages over 
most others. 
Whatever apparatus is employed, it may become necessary to apply press- 
ure directly over the sterno-clavicular articulation, by means of a thick 
compress secured with a roller. After the lapse of six or seven weeks the 
dressings may be laid aside and the arm supported in a sling for two weeks 
longer. By this time all that rest can accomplish will have been effected, 
when the use of the limb should be commenced. Notwithstanding that the 
natural relations of the bones are imperfectly restored, the usefulness of the 
arm is not seriously impaired. 
Dislocation Backward.-This may be produced by force applied both in a 
direct and an indirect way. The force acts directly when it is applied to the 
anterior surface of the clavicle near the sternal extremity; indirectly when 
it is received upon the posterior and outer aspects of the shoulder, impelling 
the end of the bone through the posterior ligaments of the articulation. 
This dislocation is less common than the one forward. The displaced end 
of the clavicle disappears in the neck; it is sometimes below and behind the 
top of the sternum; less frequently a little above it. The position of the 
bone beneath the sterno-hyoid and sterno-thyroid muscles, as alleged by 
Malgaigne, lacks confirmation. 
Symptoms.-The characteristic fullness of the stcrno-clavicular articulation 
disappears, by the retreat of the sternal end of the clavicle backward into 
the neck, leaving in its place a depression, into which the finger can be intro- 
duced. The supra-sternal fossa is thus rendered less pronounced; the shoul- 
der advances towards the median line; the head is inclined towards the 
sound side; and severe pain is experienced behind the sternum, particularly 
when the arm, which is also quite helpless, is moved. And, in cases where 
the displacement is great, there may be dyspnoea and difficult deglutition, in 
consequence of the bone pressing 
against the trachea and the oeso- 
phagus. Even the great vessels at 
the root of the neck may be pressed 
upon, when there will be the signs 
of embarrassed circulation. Along 
with the rupture of the ligaments, 
some of the innermost fibres of the 
clavicular portion of the sterno- 
cleido-mastoid muscle also may be 
torn. 
Treatment.- The reduction is 
effected by standing behind the pa- 
tient and drawing the shoulders 
upward and backward, when the 
bone will glide forward into its 
natural cavity. A posterior eight 
bandage (Fig. 921) will aid in re- 
taining the parts in their place, 
the forearm being crossed upon the 
breast and supported in abroad sling. 
This bandage can be rendered 
more effective by applying it over 
a thick roll-pledget placed between 
the shoulders. 
Should this dressing prove unsatisfactory, the patient must be made to 
assume the horizontal position on a hard mattress, with the head resting 
on a low pillow, and with the arms crossed upon the chest,-a posture 
admirably adapted to preserve the reposition of the bone. Mr. De Morgan, 
Fig. 921. 
Figure-of-eight dressing for a posterior dislocation of the 
sternal end of the clavicle. DISLOCATION OF THE ACROMIAL END OF THE CLAVICLE. 
49 
of the Middlesex Hospital, in a case of this luxation, succeeded in maintaining 
the reduction by a pad placed on the spine, over which was laid a splint ex- 
tending across from one shoulder to the other and bound by the turns of a 
roller.* This plan may be adopted should the posterior eight bandage fail. 
There is one instance of a posterior pathological dislocation of the 
clavicle recorded by Sir Astley Cooper, which was produced by the mal- 
direction of the bone consequent on a curvature of the spine, and in which 
the dyspnoea from pressure on the trachea was so great that, in order to 
save the life of the patient, Mr. Davie, of Bungay, was compelled to remove 
the sternal end of the bone. 
Dislocation Upward.-This dislocation, the existence of which was for a 
long time denied, is now accepted as a well-established, though exceedingly 
rare, injury, there being only ten examples on record,-five collected by Mal- 
gaigne, two by Hamilton, and three by Bryant. One of those occurring in 
the practice of the last-named surgeon was remarkable for being a bilateral 
luxation, the sternal extremities of both clavicles being displaced upward, so 
that their ends could be brought together by pressing the shoulders towards 
each other. The third case referred to by Mr. Bryant is a specimen in Guy's 
Hospital Museum, London. 
Causes.-This displacement is probably always produced by a force acting 
upon the top of the shoulder in such a way as to depress the acromial end of 
the bone and at the same time to force it inward. 
Symptoms.-The signs indicative of this luxation are a prominence above 
the top of the sternum (Fig. 922), a depression of the shoulder, partial ob- 
literation of the supra-sternal 
fossa, and a tense state of the 
sternal origin of the stern o- 
cleido-mastoid muscle, which is 
stretched over the end of the 
displaced bone. 
Treatment.-To restore the 
bone to its place requires that 
the shoulder shall be drawn up- 
ward and outward, while the 
head of the clavicle is pressed 
downward into its articular ex- 
cavation. This is quite an easy 
task, the great difficulty being 
to retain it in position after re- 
duction is effected. No con- 
trivance has yet been devised 
capable of effecting this indica- 
tion, and we are obliged, therefore, to be content with keeping the bone as 
nearly as possible in situ. A compress, laid over the part after reduction and 
fastened with a roller, will, when supplemented by the Fox apparatus, used for 
fracture of the clavicle, do all that bandages are capable of accomplishing. 
Simultaneous Dislocation of both the Sternal and the Acromial End of the 
Clavicle. 
This very unusual dislocation has been known to occur four times. Riche- 
randf and Marel-LavalleeJ have each reported one case. Dr. North,§ of 
Brooklyn, New York, has recorded a third, and Dr. Haynes,|| of Malvern 
Link, narrates a fourth. In the last instance, the acromial extremity was 
only subluxated. The reduction was accomplished in Dr. North's case by 
Fig. 922. 
Dislocation of the sternal end of the clavicle upwards. 
Holmes's System of Surgery, vol. ii. p. 805. f Journal Hebdomadaire, vol. ii., 1831. 
J Gazette des Hopitaux, No. 33, 1859, Holmes. 
£ New York Medical Record, April 16, 1866, Hamilton. 
|j Hamilton on Fractures and Dislocations, 5th edit., p. 572, from British Medical Journal, Jan. 27, 
1872. tA'COlCAL 
VOL. II.-4 50 
DISLOCATIONS. 
an assistant drawing the shoulders strongly backward, while the surgeon, 
with a thumb placed at either end of the bone, made pressure in such a 
manner as to correct the rotatory displacement produced by the muscles 
connected with the bone,-i.e., by pressing the sternal end backward and 
upward and the acromial end backward and downward. 
The dressing which would answer in a luxation of this nature would be 
(after carrying the shoulders back and fixing them in that position by a pos- 
terior eight roller) a compress placed over the sternal end of the clavicle and 
fastened by a figure-of-eight bandage, and a second compress, applied to the 
acromial extremity and secured by a spica of the shoulder. 
The results obtained in the treatment of the recorded cases of this accident 
are better than would, theoretically, have been anticipated. 
DISLOCATIONS OF THE SCAPULA. 
Dislocations of the scapula, commonly designated dislocations of the acromial 
extremity of the clavicle, are more common than those which occur at the 
sterno-clavicular articulation. There are three varieties of this luxation,- 
one, in which the acromion process is carried beneath the clavicle (Fig. 923); 
Fig. 924. 
Fig. 923. 
Dislocation of the scapula beneath the clavicle. 
Deformity in downward dislocation of the scapula. 
a second, in which the process is forced above the clavicle (Fig. 927); and 
a third, in which both the acromion and coracoid processes are placed above 
the clavicle. The first is the most common. 
The acromio-clavicular articulation is quite movable. The joint consists 
in a shallow depression on the acromion adapted to a slight rotundity at the 
outer end of the clavicle, and surrounded by a capsular ligament. 
Causes.-The displacements are caused by a fall or by a stroke from some 
body, acting upon either the clavicle or the acromion process of the scapula. 
They have also been produced by the arm being suddenly drawn forward 
over the head; and by a force acting against the collar-bone from below. 
Whether the acromion process is placed above or below the collar bone, 
the shoulder, losing the support of the clavicle, sinks downward and forward. 
Dislocation Downward.-Symptoms.-In the first and most common form, 
-that in which the displacement is downward,-a hard prominence, made 
by the acromial end of the clavicle, can be seen and felt at the summit of the 
shoulder, covered by the integument. There it is held between the antagon- DISLOCATIONS OF THE SCAPULA. 
51 
izing fibres of the trapezius and the deltoid, the former muscle being at its 
inner margin unnaturally prominent. (Fig. 924.) 
The arm, though disabled, and only raised with difficulty, is not rendered 
altogether helpless. It is restricted in its movements more from the injury 
to the deltoid muscle caused by the deter- 
mining violence, and from the pain which 
is experienced, than from any mechanical 
disadvantage attending the accident. 
Treatment.-The reduction is readily 
accomplished by seating the patient on a 
stool, and then, raising the shoulder up- 
ward and outward, grasping the elbow 
with one hand, while with the other hand 
the clavicle is depressed. 
Another plan is to plant the knee between 
the shoulders, and draw them upward and 
backward, until the bone returns to its 
proper position. 
After the adjustment, a compress must be 
placed over the acromio-clavicular articula- 
tion, and the arm confined with a Velpeau 
roller dressing, or a spica of the shoulder. 
(Fig. 925.) 
The reduction is rarely ever permanently 
retained, there being always a latitude of 
movement between the bones much greater 
than normal. But this does not appear 
to weaken the arm materially. 
Fig. 925. 
Spica dressing for downward dislocation of 
the scapula. 
Dislocation Upward.-For a long time the possibility of this luxation was 
denied, but it has come to be recognized as a veritable displacement. Three 
instances of the dislocation have been observed; and although only one was 
verified by a post-mortem examination, yet in one of the others the recorded 
symptoms of the injury seem to be so complete as to leave little doubt that 
it was really of the nature described. The only thing which militates against 
the acceptance of the third is the statement that the luxation was complete 
without a visible trace of the injury. These cases have been collected by 
Malgaigne. 
The relation of the bones in this luxation is such that the clavicle is placed 
beneath the acromion,-between it and the coracoid process; and in M. 
Tournel's case it extended so far towards the supra-sternal fossa as to be 
felt on the outer side of the acromion. 
Cause.-To place the clavicle in so improbable a situation would necessitate 
the application of a severe force at its acromial extremity, with simultaneous 
counter-pressure made on the outer and anterior surface of the shoulder, 
and in a direction also by which the latter would be forced backward and 
upward. 
Symptoms.-In this upward displacement, the acromion process should 
appear abnormally prominent, and a considerable sulcus should be felt along 
its inner border. The space between the shoulder and the sternum will be 
lessened, the ability to raise the arm diminished, and the whole contour of 
the parts changed. (Fig. 926.) 
Treatment.-The same manipulation which is employed to reduce the 
downward luxation of the scapula will be proper for the correction of the 
displacement upward; namely, planting the knee between the shoulders and 
drawing them upward and backward until the bones resume their natural 
relations. Then the endeavor should be made to preserve them in place by 
means of a Velpeau or a Fox dressing,-a task which will be found difficult 
of execution, and promising no better results than in the former dislocation. 52 
In two of the cases recorded the dislocations were never reduced. Not- 
withstanding the unsatisfactory nature of the reduction, it appears from 
the history of the cases referred to that the usefulness of the arm was but 
little impaired. 
DISLOCATIONS. 
Fig. 926. 
Fig. 927. 
Dislocation of the scapula above the clavicle. 
Deformity in upward dislocation of the scapula. 
The Second variety of the Upward Dislocation is one in which the 
clavicle is placed beneath the coracoid process of the scapula. This dislocation 
was first described by Godemer* about the year 1843. This writer published 
5 cases of the injury, which, with one noticed by Pinjou,f constitute all the 
examples of this accident that have been recorded up to the present time. 
Causes.-This displacement could not occur without the operation of two 
forces,-the one forcing the shoulder upward, outward, and backward, and 
the other driving the acromial end of the clavicle downward. 
Symptoms.-There will be a striking depression along the inner side of the 
acromion; an unusual prominence of the latter process and of the coracoid ; 
a hard ridge formed by the shoulder, extending obliquely downward towards 
the axilla; pain and restricted inward movements of the arm; and an increase 
of distance between the sternum and the summit of the shoulder. 
Treatment.-The arm being flexed and brought to the side by an assist- 
ant, in order to relax the clavicular portion of the pectoralis major muscle, 
it should next be carried forcibly upward, outward, and backward, while the 
surgeon, grasping the clavicle and disengaging it from beneath the coracoid 
process, presses it into its proper site. 
Dislocation of the Inferior Angle of the Scapula. 
The latissimus dorsi muscle, where it passes over the lower angle of the 
scapula, is occasionally displaced, so as to slip beneath this extremity of the 
bone. The accident sometimes occurs to children as a result of lifting them 
by one arm over street-gutters. 
The displacement may be recognized by the projection of the lower angle 
of the scapula, which is increased when the arm is drawn forward; by the 
resistance encountered in the same movement; and sometimes by the pain 
experienced in the region of the injury. Though I have seen what I be- 
* Godemer, Recueil des Travaux de la Soci<5t€ M6dicale d'Indre-et-Loire, 1843. 
f Pinjou, Jour, de M6d. de Lyon, Juillet, 1842. From Vidal, Hamilton. DISLOCATIONS OF THE HUMERUS. 
53 
lieved to be this displacement in two instances, still, I think it may be deemed 
an uncommon accident. 
To correct the disarrangement, it is advised to relax the muscle as much 
as possible, by carrying the arm well back, and, while it is thus situated, to 
hook the muscle into position with the fingers. 
In the cases to which reference is made, my efforts at reduction were en- 
tirely unavailing. 
DISLOCATIONS OF THE HUMERUS. 
The great variety and extent of movement allowed by the scapulo-humeral 
articulation are due to the shallowness of the glenoid cavity of the scapula, 
to the extensive hemispherical surface of the head of the humerus, and to 
the magnitude of the capsular ligament. The chief protection to the joint 
consists in what may be called the extra-capsular cavity, in which the head of 
the bone moves, and which is formed by the acromion and coracoid processes 
with their connecting ligament. 
Frequency.-While these peculiarities of organization, as regards the 
mobility of the scapula, enlarge very much the range and variety of the 
movements which the upper extremity is capable of executing, they never- 
theless render the articulation less secure; and hence dislocations of the 
humerus exceed in frequency those of all other joints combined. In 912 
luxations treated at the Pennsylvania Hospital, 458 belonged to the scapulo- 
humeral joint. Of this number, 218 occurred between twenty-five and forty- 
five years of age. After sixty-five the number rapidly diminishes. Malgaigne 
found that out of 491 dislocations, 321 were of the shoulder. Seven cases 
under fifteen years are noted. A few instances of this luxation have been 
observed at a much earlier period of life. Dr. John Ashhurst mentions one 
which he saw at two years; Dr. Packard records another at the same age; 
and one has been noticed by Flower and Hulke, admitted into the Middlesex 
Hospital, in a child fourteen days old. 
Males, as might be expected from the nature of their occupations, suffer 
more than females; that is, in about the proportion of seven of the former 
to one of the latter. 
Varieties,-The numerous varieties of this luxation which have been de- 
scribed by different writers I have no disposition to question. They have, 
undoubtedly, a certain amount of interest in the direction of pathological 
exactitude; but practically, in all that concerns the recognition and treat- 
ment of this luxation, they are valueless. 
There are three primary dislocations of the humerus. First, there is the 
dislocation downward and slightly inward, or subglenoid, sometimes termed 
axillary; second, forward,-with two varieties, the subcoracoid and the sub- 
clavicular ; third, backward on the dorsum of the scapula, or subspinous. 
The last-named luxation is comparatively rare, there being only about 
thirty cases on record. The most common variety is that in which the 
humerus is displaced forward, or the subcoracoid luxation. 
Dislocation Downward {Subglenoid}.-In this luxation the capsular liga- 
ment is extensively torn at its lower surface, and the head of the humerus, 
slipping through, takes its position on the anterior border of the scapula, im- 
mediately below the glenoid cavity. (Fig. 928.) Or it may be a little higher 
towards the subscapular surface of the neck of the bone, close to its articu- 
lating cavity. In either case it is situated between the tendons of the triceps 
extensor cubiti and subscapular muscles. In two specimens of old unreduced 
luxations in my possession, such are the positions of the head of the humerus; 
and there they have formed for themselves imperfect articular cavities. 
The axillary blood-vessels and nerves suffer more or less from pressure, 
the deltoid being in some instances paralyzed from the damage done to the 
circumflex nerve. The muscles which surround the articulation are variously 54 
DISLOCATIONS. 
affected. The deltoid muscle and the muscles on the dorsum of the scapula, 
the supra-spinatus and infra-spinatus, are put upon the stretch, especially 
the first two. The same is true, but in a 
less degree, of the subscapularis and the 
coraco-brachialis, both of which muscles 
may be partially torn. Even the greater 
tuberosity of the humerus may be detached. 
The long tendon of the biceps may be 
dragged out of its groove. And, as the hu- 
merus is below the articulating cavity of the 
scapula, and, therefore, nearer to the origin 
of the teres major and teres minor muscles, 
these muscles are slightly relaxed. 
Causes.-This luxation is liable to occur 
in a variety of ways. It may follow a fall 
upon the anterior surface of the shoulder. 
A blow on the same part, when the arm is 
in the extended position, may readily pro- 
duce the displacement; and it may also be 
caused by a force which drags the arm over 
the head. In three instances I have seen 
the dislocation produced by muscular con- 
traction while patients were writhing in a 
paroxysm of epilepsy. 
The muscles of the scapula sometimes 
become so relaxed, from constitutional weakness or from paralysis, as to 
allow a dislocation of the humerus to take place without any laceration of 
the capsular ligament. 
Forward Dislocation.-There are two forms of the forward dislocation, 
-the subcoracoid, and the subelavicular. 
In the subcoracoid form, the capsular ligament is lacerated on its anterior 
aspect, and the head of the bone, passing through, assumes a position on the 
inner surface of the neck of the scapula, below the coracoid process. (Fig. 
929. This luxation is the most common. Occasionally the head of the 
humerus is found farther back upon the subscapular fossa, beneath the sub- 
scapular muscle. This displacement was perhaps first noticed by Sir Astley 
Cooper. It has also been described by Velpeau and by Malgaigne, the former 
designating it a subscapular and the latter a subcoracoid luxation. Dr. 
Wood* and Dr. Parker,f of New York, have also each given an example of 
this dislocation. The subcoracoid luxation may, secondarily, be produced 
either by the spasmodic contraction of the clavicular part of the great 
pectoral and coraco-brachial muscles, or by manipulations converting the 
downward or subglenoid variety into the former. 
The second form of the forward dislocation is the subclavicular, in which 
the head of the bone rests on the side of the chest, below the clavicle. (Fig. 
930. This displacement answers to the intra-coracoid of Nelaton. 
When the head of the bone thus rests on the side of the chest below the 
clavicle, it is covered by the pectoralis major and minor muscles. The supra- 
spinatus and infra-spinatus muscles, and those portions of the deltoid which 
arise from the acromion process and from the spine of the scapula, together 
with the inner fibres of the coraco-brachial muscle, and the short head and 
long tendon of the biceps, are all put upon the stretch. The subscapularis 
is carried upward in the direction of the displacement. The axillary vessels 
and plexus of nerves are subjected to severe pressure. Laceration of the 
supra-spinatus and infra-spinatus muscles may occur; or, if they are strong 
enough to resist the disturbing force, the tubercles upon which their tendons 
are attached may be detached from the bone. In rare instances, the tendon 
Fig. 928. 
Subglenoid luxation'. 
* New York Journal of Medicine, May, 1850, p. 282, Hamilton, 
f Cooper's Surgical Dictionary, by Reese. DISLOCATIONS OF THE HUMERUS. 
55 
of the subscapularis has been torn away from its connection writh the lesser 
tuberosity. 
Causes.-Any force which carries the forearm violently backward and 
Fig. 930. 
Fig. 929. 
Subcoracoid luxation. 
Subclavicular luxation. 
upward, by pressing the head of the humerus against the inner part of the 
capsular ligament, may cause forward (subcoracoid) luxation. It is often 
produced by blows or falls upon the outer surface of the shoulder. When 
the violence is sudden and intense, the head of the bone may be carried be- 
yond the innermost limits of the coracoid process, and it may assume the 
subclavicular position. In a case given by Colles, the force was sufficient to 
fracture the coracoid process.* 
Backward or Subspinous Dislocation.-In this luxation the head of the 
bone occupies the dorsum of the scapula, posterior to the glenoid cavity and 
immediately below the spine. (Fig. 931.) 
The effects on the scapular muscles will be 
to render them tense, or to tear the subscap- 
ularis and supra-spinatus; to relax the infra- 
spinatus and the teres minor; and to stretch 
the long tendon of the biceps and the clavic- 
ular part of the deltoid. 
Malgaigne has described two luxations on 
the dorsum of the scapula,-the subacromial 
and the subspinous,-a distinction possessing 
no value, as it only serves to express a very 
trifling difference in the position of the head 
of the bone. 
Cause.-Luxations backward are produced 
by force applied to the anterior surface of the 
shoulder, possibly by any cause dragging the 
forearm forward. 
Partial Luxations, or Subluxations.-A 
form of incomplete dislocation of the humerus 
has been described by Sir Astley Cooper and by Malgaigne. The existence 
of this injury has been predicated upon the presence of a depression beneath 
the acromion, upon the posterior aspect of the joint, and upon a well-rounded 
Fig. 931. 
Subspinous luxation. 
® Dublin Quarterly Journal, 1855, vol. xx. 56 
DISLOCATIONS. 
prominence formed by the head of the humerus lying in contact with the 
coracoid process. To the anatomist such a dislocation, independent of a frac- 
ture of the coracoid process, will appear impossible ; and, as this luxation has 
never been verified by dissection, there is no sufficient reason for assigning it 
a place within the domain of surgical pathology. Mr. Soden* attributes the 
unusual position of the head of the humerus in these cases of so-called par- 
tial luxation to rupture of the long tendon of the biceps muscle, in conse- 
quence of which the supra-spinatus draws the bone out of its normal place. 
I have in at least three instances seen the condition present which is said 
to characterize this supposed displacement; and, from the nature of the 
precedent injuries, I have been disposed to refer the anterior fullness on the 
inner aspect of the joint to a loss of power in the posterior scapular muscles, 
in consequence of which the head of the humerus is drawn unusually in- 
ward by the subscapularis, and inward and upward by the clavicular fibres 
of the pectoralis major and deltoid muscles; and likewise, though in a less 
degree, by the coraco-brachial and the short tendon of the biceps. 
Partial displacement may be produced by chronic articular arthritis, as has 
been pointed out by Dr. Adams. I have before me a specimen in which the 
luxation (subcoracoid) is complete from this cause. The glenoid cavity and 
the parts contiguous are studded with irregular nodules of bone, and the 
surface of the head of the humerus is completely eburnated. The tendon of 
the biceps, in this case, has been destroyed. 
A backward partial dislocation, however, may occur without rupture of 
Fig. 932. 
Loss of rotundity of the shoulder and concavity beneath the acromion in subglenoid and subcoracoid luxations. 
a, front view; b, posterior view. 
the capsular ligament, the head of the bone resting upon the posterior lip of 
the glenoid cavity. 
Common Signs of Scapulo-Humeral Dislocations.-There are certain signs 
which are common to all varieties of dislocation of the humerus. There 
is first a marked alteration in the external contour of the shoulder, which, 
in persons somewhat lean, is very striking indeed. The rotundity of the 
shoulder disappears. It becomes flattened, and instead of the natural soft- 
ness of the parts, they have a tense feel. The acromion process is abnor- 
® London Medical Gazette, July, 1841 COMMON SIGNS OF SCAPULO HUMERAL DISLOCATIONS. 
57 
mally salient or prominent, being sharply defined both to the eye and to the 
touch. Beneath the acromion is a depression into which the finger can be 
readily sunk (Fig. 932), and which is rendered still more perceptible when 
the arm is raised from the body. In con- 
sequence of the traction made on the deltoid 
muscle, the elbow stands off from the body, 
with a single exception, viz., in subspinous 
luxation. Nor can the hand of the injured 
limb, if the limb is pressed to the side, be 
placed upon the shoulder of the sound side. 
The arm is fixed and constrained in all 
its movements. A round, resisting body- 
the head of the humerus-can be felt in its 
abnormal position. In the subglenoid and 
subcoracoid forms, this prominence will be 
discovered in the axilla, and will become 
more marked when the limb is carried off 
rom the side. It can be identified as the 
lead of the humerus if, on placing upon it 
the fingers of one hand, it is found to move 
with the rotation of the arm. 
In the subcoracoid luxation the prom- 
inence of the head of the humerus will be 
found immediately below the coracoid pro- 
cess. (Fig. 933.) In the subclavicular 
variety it will be found below the clavicle. (Fig. 934.) And in the sub- 
spinous luxation it will be detected below the spine of the scapula. (Fig. 935.) 
Fig. 933. 
Subcoracoid luxation. 
Fig. 934. 
Fig. 985. 
Subclavicular luxation. 
Subspinous luxation. 
Pain is felt extending down the arm, and often accompanied by numbness 
of the fingers, in consequence of pressure on the axillary plexus of nerves. 
And, lastly, there is a loss of from one to two inches in the vertical circum- 
ference of the shoulder-joint of the injured side. This last-named sign can 
be determined by the plan first pointed out by Mr. Callaway,* viz., measuring 
with a tape-line over the acromion and through the axilla. This test is, 
* Callaway upon Dislocations and Fractures of the Clavicle and Shoulder-Joint. 58 
DISLOCATIONS. 
however, not reliable after the traumatic swelling sets in, in which case the 
measurement may greatly exceed that of the sound shoulder. 
The variations which are found to exist between the different forms of 
scapulo-humeral dislocations will best appeal' by placing them in contrast, as 
below: 
DISLOCATION DOWNWARD. 
{Subglenoid.') 
Shoulder extremely flattened. 
Acromion very prominent. 
Depression below the entire 
arch of the acromion. 
Elbow projecting from the side 
of the body. 
Axis of humerus directed be- 
low the glenoid cavity. 
Inability to place the hand of 
the injured side on the sound 
shoulder. 
Presence of a hard hemispher- 
ical tumor in the axilla. 
Pain and numbness in the arm 
and fingers. 
FORWARD. 
{Subcoracoid.) 
Flattened, but not extremely 
so. 
Prominent. 
Greatest at the posterior part. 
Projecting from side of the 
body. 
Direction anterior to and be- 
low glenoid cavity. 
Inability to place the hand of 
the injured side on the sound 
shoulder. 
Presence of a hard hemispher- 
ical tumor in the axilla, but 
higher. 
Pain and numbness in the arm 
and fingers very marked. 
BACKWARD. 
(Subspinous.) 
Moderately flattened. 
Moderately prominent. 
Greatest at the anterior part. 
Elbow to the side of the body 
and arm advanced. 
Directed posterior to the glen- 
oid cavity. 
Ability to place the hand of 
the injured side on the sound 
shoulder. 
Absence of a hard tumor in the 
axilla, but one present below the 
spine of the scapula. 
Much pain in the shoulder, 
little in the arm, and no numb- 
ness of the fingers. 
Subclavicular Form. 
The acromion most prominent 
of all the luxations. A round 
hard tumor below the clavicle. 
Elbow directed backward. 
Diagnosis.-Notwithstanding that the signs of scapulo-humeral dislocation 
are usually very striking and clear, the accident is frequently overlooked. 
Every year I see a number of such cases. Errors of this kind ought not to 
occur if the patient is seen shortly after the injury befalls him. But when 
some time has elapsed before the practitioner is called in, and when con- 
siderable swelling exists, measurably effacing the prominences and the flatten- 
ing which commonly form such characteristic features of the displacement, 
the mistake may easily be committed. The injuries with which this disloca- 
tion may be confounded are contusions, fracture through the neck of the 
scapula, fracture near the head of the humerus, and fracture of the acromion 
process. 
With a view to render the examination thorough, when any doubt as to 
the nature of the injury exists, the patient should be placed under the influ- 
ence of an anaesthetic. If the different movements of the arm can be made 
by the surgeon with freedom, and on raising the arm above the level of the 
shoulder the finger cannot be thrust into a space beneath the acromion, and 
if the head of the humerus cannot be felt in the axilla on the front of the 
chest nor below the spine of the scapula, and if, also, the arm can be placed, 
without an effort, vertically along the side of the body, the elbow not pro- 
jecting outward, forward, or backward, the idea of luxation may be confi- 
dently dismissed. 
In fracture of the neck of the humerus, of the neck of the scapula, or of 
the acromion, there will be preternatural mobility, rude crepitation, and a 
readiness of reduction, with a tendency to the recurrence of the deformity 
as soon as the limb is released from the manipulating force. The prominence 
of the upper end of the lower fragment, which is sometimes felt through 
the pectoral muscles, in a fracture of the surgical neck of the bone, can be 
readily distinguished from the smooth, hemispherical head of the humerus 
by its irregular, spiculated form. Even in separation of the epiphysis, the 
diaphysis, though not presenting spiculin, has a plain, flat surface, instead of 
a round one like the head of the humerus. This circumstance, taken in con- SCAPULO-HUMERAL DISLOCATIONS. 
59 
nection with the fact that epiphyseal fractures occur at a period of life when 
dislocations are uncommon, would leave little room for error. 
I have purposely omitted any reference to the occupation or non-occupa- 
tion of the glenoid cavity of the scapula by the head of the humerus, and 
also to the presence or absence of flattening of the shoulder, as there are 
contusions of the muscles about the articulation, which, by permitting the 
head of the bone to drop, may create a considerable vacancy beneath the 
acromion, simulating the condition presented in luxation. And, on the 
other hand, the inflammatory transudation may readily restore the normal 
rotundity to the shoulder. 
Treatment.-There are two methods practiced for the restoration of a 
dislocated humerus,-the one by manipulation, and the other by extension 
and counter-extension. 
Reduction by manipulation.-This plan, in its application to dislocations of 
the shoulder, has been reduced to a system by Professor II. H. Smith, of 
Philadelphia. Fig. 936 represents the various positions of the limb during 
the different stages of reduction by this method. It consists in simply 
placing the limb in such a posture 
that those muscles connected with 
the upper extremity of the hu- 
merus, and which are rendered 
tense by the displacement, shall 
be relaxed, and the head of the 
bone lifted or rolled into place. 
From a number of studies 
which I made some years ago 
upon the cadaver, on the mech- 
anism of this luxation and its re- 
duction, I am led to believe that 
the coraeo-humeral part of the 
capsular ligament remains untorn, 
and that it performs an impor- 
tant office in conducting the head 
of the bone into the glenoid 
cavity, during properly applied 
efforts at reposition. 
In the subglenoid dislocation, the muscles which are placed upon the stretch, 
and which, consequently, fix the bone in its unnatural position against the 
elevated lip of the glenoid cavity, are the supra-spinatus and the deltoid. In 
the subcoracoid and subclavicular forms of the forward luxation, in addition 
to the supra-spinatus and deltoid, the infra-spinatus and teres minor muscles 
are put upon the stretch. And in the posterior or subspinous displacement, 
the subscapularis, teres major, pectoralis major, and supra-spinatus muscles 
are rendered tense. In all the varieties of the luxation the long tendon of 
the biceps is on the stretch. 
Keeping these facts distinctly before the mind, the surgeon, understanding 
the origin and insertion of the scapulo-humeral and thoraco-humeral mus- 
cles, will have little difficulty in directing the arm in such a manner as to 
remove all resistance, and to bring its movement entirely under his will. 
In the demonstration of the method by manipulation, let us take, for 
example, a case of subglenoid luxation. The patient, having been placed in 
the recumbent position on a bed or a table, should be etherized. The first 
indication is to remove the strain from the long head of the biceps, and to 
relax the deltoid and supra-spinatus muscles. This is accomplished by flex- 
ing the forearm upon the arm, grasping the latter at the elbow and raising it 
upward along the side of the head by abduction, and then supinating the 
forearm. While it is in this position, let the surgeon place two or three 
fingers of the other hand upon the head of the humerus, which will appear 
under the skin of the axilla. (Fig. 937.) And as the arm is drawn out- 
Fig. 936. 
Elevation, abduction, and adduction of the arm, with supina 
tion of the forearm, in restoring a subglenoid dislocation. 60 
DISLOCATIONS. 
ward, and is brought to a right angle with the chest, let the head of the 
bone at the same time be lifted into its socket. 
When the dislocation is for- 
ward, either subcoracoid or sub- 
clavicular, the arm, after being 
elevated, should be rotated exter- 
nally before being carried down, 
in order to relax still further the 
supra - spinatus, infra - spinatus, 
and teres minor muscles, or such 
of them as may not be torn. 
Professor Smith directs that the 
rotation be made before the ele- 
vation of the arm, or abduction; 
but I find that it is more easily 
and thoroughly done after the 
strain on the external capsular 
muscles has been lessened. 
When the dislocation is back- 
ward, the arm, after being car- 
ried to extreme abduction, must 
be rotated inward, to relax the 
subscapular muscle, and the head 
of the bone be pushed forward 
with the thumb and fingers dur- 
ing the movement of adduction. 
Extension and counter-extension. 
-In reduction by extension and 
counter-extension, the arm may 
be placed in three positions: 
first, downward, parallel with the 
body; second, upward, parallel 
with the side of the face and the head; and, third, outward, at a right angle 
with the body. 
First position. - The 
simplest way of using 
the former method is 
that employed by Sir 
Astley Cooper. The pa- 
tient is placed upon a 
low bed, table, or settee, 
in a horizontal position. 
A jack-towel or a sheet 
is next to be secured to 
the arm a short distance 
above the elbow-joint, 
and the forearm is to be 
flexed at a right angle 
with the arm. The sur- 
geon, taking his seat 
upon the bed, with one 
foot resting on the floor, 
plants the other, with- 
out boot or shoe, against the axilla of the patient, there being interposed a 
folded towel to protect the skin. (Fig- 938.) 
A steady, continuous, and gradually-increasing extension is now made for 
a minute or two by pulling upon the towel, when the bone ordinarily slips 
into its socket with a sound which can often be distinctly heard. 1 have 
found, when using this plan, that after making extension for a short time 
Fig. 937. 
Reduction by manipulation as practiced by author. 
Fig. 938. 
Reduction with the heel in the axilla. SCAPULOHUMERAL DISLOCATIONS. 
61 
the reduction was facilitated by carrying the arm somewhat across the body, 
as, by so doing, the side of the surgeon's unbooted foot becomes a fulcrum 
against which the bone is pried outward towards its articulating cavity. 
When greater force becomes necessary, the extension may be increased 
by one or more assistants taking hold of the band • and the exhibition of an 
anaesthetic should not be omitted. 
Second position.-Eeduction with the arm in the second position,-i.e., par- 
allel with the side of the head and face,-commonly called the method of La 
Mothe (Fig. 931), is more easily accomplished than by any other method in 
which extension and counter-extension are employed. It is the one to which 
I always give the preference when manipulation fails, and when also the 
luxation is not an old one. 
The dangei' to the blood-vessels when these, by inflammatory changes, 
have become glued to the head of the bone, is certainly greater, if much 
force is applied in this position of the arm, than is incurred in any other 
method. It was while attempting to reduce an old and obstinate dislocation 
of the humerus by this plan of La Mothe that I once ruptured the axillary 
vein; and, although the patient did not perish, yet for some days she was in 
a very critical state. 
The advantage of this method in recent luxations will, however, be ob- 
vious to any one who will recall the anatomical relations of the parts. For 
it insures most effectually the relaxation of those muscles which detain the 
dislocated bone in its unnatural position, viz., the supra-spinatus and the 
deltoid. 
To apply the reductive 
force by this plan, the pa- 
tient should be placed in 
the recumbent position on 
a table, or obliquely across 
abed. The surgeon, taking 
hold of the limb of the in- 
jured side above the elbow 
with one hand, and planting 
the other on the top of the 
shoulder (Fig. 939), in order 
to fix the scapula, makes 
strong traction on the arm. 
The bone will frequently 
slip into its socket on the 
slightest extension being 
made. But if it resists, let 
the limb, while the traction 
is still maintained, be rotated and carried a little off from the body, counter- 
pressure being made by the foot placed upon the shoulder. (Fig. 940.) And 
as it is being returned to the natural position by the side, the surgeon will 
generally be rewarded by feeling the head of the bone return to the glenoid 
cavity. 
If still foiled in effecting the reposition, an advantage may be gained by 
securing the aid of an assistant, who shall press the head of the bone upward 
and outward towards the articulating cavity, while the arm, still strongly 
extended as before, is being brought down to the side. 
Third position.-The patient being placed on a bed as in the other methods, 
the arm is to be carried to a right angle with the body. The surgeon now 
grasps the arm above the elbow, and, planting his foot across the posterior 
fold of the axilla, so as to fix the scapula, he begins to make extension. (Fig. 
941.) As soon as the muscles arc found to yield, the arm must be directed 
towards the side, with a view to guiding the bone into its socket. 
The late Professor N. E. Smith, of Baltimore, occasionally adopted a plan 
which was originated by his father, Nathan Smith, of New Haven, for fixing 
Fig. 939. 
La Mothe's mode of reducing a luxated humerus. Scapula fixed by 
the hand. 62 
DISLOCATIONS. 
the scapula during the efforts made for restoring a dislocated humerus while 
the limb is at a right angle with the body. The plan was this. The patient 
Fig. 940. 
Fig. 941. 
Reduction with the arm at a riglit angle with the body. 
Scapula fixed by the foot. 
having been seated on a chair, a band was passed through the axilla, and 
one of its ends carried across the chest, the other across the back, and con- 
tinued along the anterior and posterior aspects of the sound arm, to the 
wrist of which they were secured by a circular band. Another band was 
then attached to the wrist of the injured arm; and still another was passed 
over the top of the shoulder, and brought down front and back and tied 
fast under the chair. By now making counter-extension from the sound 
arm, while extension was simultaneously made from the injured one, the 
scapulae, through the trapezii muscles, were fixed. While these forces were 
being exerted at the wrists of the extended arms by the assistants, the sur- 
geon, with his foot resting upon the chair, pressed his knee into the axilla of 
the patient, thus lifting the bone into its place. (Fig. 942.) 
Sir Astley Cooper was in the habit of restoring luxations of the humerus 
by placing a foot on the chair occupied by the patient and, with one hand 
on the top of the shoulder and the other hand grasping the arm, bending the 
limb forcibly over the knee planted in the axilla. (Fig. 943.) 
If it should be deemed necessary to employ still greater force than that 
attainable by the measures already described, recourse can be made to the 
compound pulley, counter-extension being used, and the scapula being fixed 
by a strong band, slit in its centre and slipped over the arm to the axilla, 
after the plan of Sir Astley Cooper. (Fig. 944.) 
Except in cases where surgical assistance is early at hand, an anaesthetic 
should always be administered before any attempt at reduction is made. 
By whatever means a dislocation of the shoulder is restored, it is necessary 
afterwards, to prevent a recurrence of the displacement, that the arm should 
be secured to the body for two weeks. The best means of doing this is a 
Velpeau bandage. 
After its removal, the arm should be carried for two weeks in a sling, 
and during this time movements should frequently be practiced, with a 
view to establishing the function of the joint. SCAPULO-HVMERAL DISLOCATIONS. 
63 
If much pain and swelling follow the accident, the application of leeches 
Fig. 942. 
N Smith's method of reduction. 
about the joint will aid in obviating future stiffness in the movements of 
Fig. 943. 
Fig. 944. 
Sir Astley Cooper's plan of reduction over the knee. 
Pulley extension. 
the shoulder. Keeping the articulation enveloped in a lotion of laudanum 
and water will also contribute much to the comfort of the patient. 64 
DISLOCATIONS. 
Old Unreduced Luxations of the Humerus.-How to deal with cases of this 
kind is often a very perplexing question. The resistance encountered is not 
always in exact ratio with the duration of the dislocation. I have in several 
instances experienced more difficulty in replacing a luxated humerus of three 
weeks' standing than with one which had remained unreduced for three 
months. Yet, as a rule, the more ancient the dislocation the greater will be 
the obstacles to its reposition. 
If the bone has been out of place for months, and is moderately movable 
in its new position; if, following the injury, there was a history of severe 
inflammation, uniting most probably the blood-vessels and also the axillary 
plexus of nerves to the head of the bone; and if, in addition, there is no 
severe pain experienced in the limited use of the arm still possible, the sur- 
geon will do well not to urge reduction. If, however, the patient suffers severe 
pain, rendering the limb quite helpless, and if he insists on an effort being made 
to replace the bone, after a full understanding of the dangers incurred, the 
surgeon will be justifiable in making the attempt, never, however, presuming 
to transcend what, in his own judgment, is the limit of safety in the use of 
the measures which he may employ for the purpose of reduction. 
In the management of a case of this kind, after the etherization of the 
patient, the first thing to be done is to separate the head of the bone from 
its surrounding attachments. This is best done by gentle but gradually-in- 
creasing rotation. When the detachment has been accomplished (which may 
be reasonably conjectured by the increased freedom with which the bone 
moves), an attempt may be made to replace it by manipulation. Should 
manipulation fail, a resort may be had to the pulley, or to some of the differ- 
ent appliances for extension which have been described. Often it will be 
found advantageous not to employ these forcible plans of extension at first, 
but to be content for the first few days with repeated efforts at breaking up 
adhesions, so that less resistance may be encountered and less danger to the 
vessels incurred should it eventually prove necessary to employ extraordi- 
nary force. Should these measures fail, there remains the operation of Dr. 
Mears, that of dividing, by means of an Adams saw, subcutaneously, the 
surgical neck of the humerus, and establishing a false joint. The accidents 
which may occur during the employment of forcible measures at reduction 
are laceration of the muscles, rupture of blood-vessels, and injury to nerves. 
A curious instance of the first-named accident occurred at St. Bartholomew's 
Hospital,* during an attempt to restore a dislocated humerus of eight weeks' 
standing, in which the pectoral muscles were torn and the axilla laid open, 
although no force was used other than that exerted by the hands of a house- 
surgeon pulling on the arm and having his unbooted foot in the axilla. The 
muscles, in this case, were in a state of degeneration. 
Rupture of the Axillary Artery.-Dr. Willard, in an excellent paperf on 
rupture of the axillary artery and vein, has collected 19 cases of this accident, 
12 of which proved fatal, 6 recovered, and 1 was not determined. The symp- 
toms which indicate this lesion are a sudden swelling in the axilla and under 
the pectoral muscles,' absence of the pulse at the wrist, pallor of the face, 
and, in some instances, syncope. When the opening in the vessel is small, 
or when the laceration does not extend through all its coats, the accident 
may not be immediately detected ; it being only recognized when the accu- 
mulation of blood or the dilatation of the weakened vessel has attained con- 
siderable magnitude and has assumed the characteristics of an aneurism. It is 
from this circumstance that even surgeons of eminence have been led into errors 
of diagnosis which have been followed by fatal consequences. Thus, Dupuy- 
tren opened a swelling which appeared in the axilla of a woman two months 
after the reduction of a dislocated shoulder, supposing it to be an abscess. 
Complications. 
* Lancet, July 6, 1878. 
f Philadelphia Medical Times, August 16, 1873. COMPLICATIONS OF SCAPULO-HUMERAL LUXATIONS. 
65 
The patient perished from hemorrhage. A similar mistake was committed 
by Pelletan. Auscultation of the tumors would have prevented both of these 
catastrophes. 
Treatment.-Upon the occurrence of a sudden axillary or pectoral swelling, 
pressure should be instantly made over the subclavian artery until the nature 
of the tumor is clearly revealed. And if it is ascertained to arise from a 
rupture of the axillary artery, there remains either the ligature of that vessel 
above and below the laceration, or the ligature of the subclavian artery. 
Blackman, Callender, and Lister, after such an accident, have each tied the 
axillary artery. Notwithstanding, the patients all died. In Callender's case, 
gangrene of the limb followed, though the immediate cause of death seems 
to have been some pulmonary complication. Mr. R. Adams has recorded 
a case of recovery after ligature of the axillary artery above and below the 
point of rupture. 
Gibson, Nelaton, Warren,* and Adams each tied the subclavian artery. 
The cases of Warren and Adams proved successful; that of Gibson, fatal; 
and in that of Nelaton the result is not stated. In Warren's case the lacera- 
tion of the vessel was caused by the boot of the surgeon while making 
counter-extension. 
When it has been once determined that the axillary artery has been torn, 
the axillary space should be freely laid open, the blood-clots turned out, and 
a ligature applied both above and below the lesion in the vessel. This course 
would seem preferable to ligating the subclavian artery. For though in the 
latter case the hemorrhage would be controlled at the time, there would still 
remain the risk of secondary bleeding as soon as the collateral circulation 
was well established. 
If the axillary artery is tied, and secondary hemorrhage follows, the only 
alternative left to the surgeon is amputation at tire shoulder-joint. 
Laceration of the axillary veins.-There are extravasations of blood met 
with after the use of forcible measures at reduction, which come from com- 
paratively small vessels, chiefly veins, which, though they cause the surgeon 
some uneasiness, are not of sufficient gravity to justify any operative measures 
beyond pressure and the application of cold. To distinguish these collections 
from those which are due to a rupture of the main artery or vein, attention 
must be given to the rapidity with which the swelling forms, the absence or 
presence of the radial pulse, the coloi' of the face, and the strength of the 
patient. 
In the paper of Dr. Willard, to which allusion has been made, 2 cases of 
rupture of the axillary vein are recorded; 1 by Froriep and 1 by the author. 
The first proved fatal, the last recovered. There are also noticed 3 cases 
in which both the axillary artery and the axillary vein were torn, 2 of 
which were fatal, and 1 was not determined. We have, then, a total of 24 
cases of rupture of the axillary vessels, 15 terminating fatally, 2 uncertain, 
and 7 recovering. 
Injury of nerves.-The axillary plexus of nerves or some of its branches 
may be damaged in these forcible attempts to reduce an old luxation of 
the humerus, causing paralysis of the entire arm, or of certain groups of 
muscles. 
Fracture.-Several times has the humerus been broken while efforts were 
being made to replace an old dislocation. Hamilton notices three instances 
of this complication. The same accident happened in my own experience 
while attempting to reduce an old dislocation of the humerus in an aged 
female, before a medical class at the Pennsylvania Hospital. A similar frac- 
ture occurred in the hands of Dr. Hunt at the same institution, and under 
like circumstances. In my own case, the bone gave way at the surgical neck, 
and during rotation. In two of the cases noticed by Hamilton, it was during 
the same kind of movement that the humerus gave way. When the fracture 
takes place at the surgical neck, I do not regard it as a calamity, but rather 
* Warren, American Journal of the Medical Sciences, vol. xi., New Series, 1846. 
VOL. II.-5 66 
as a desirable occurrence, since by keeping up repeated movements a false 
joint can be established, which will in a great measure restore the usefulness 
of the limb; such was the result in my own case. 
Diffused abscess.-The inflammation which ensues upon the forcible disrup- 
tion of old adhesions between the head of the bone and the tissues of the 
axilla may be followed by abscess. Mr. Hutchinson, of London, lost a patient 
from this cause. 
Fracture of the lip of the glenoid cavity of the scapula may accompany a lux- 
ation. It is caused by the head of the bone being violently impelled against 
the margin of the articulating cup. This lesion existed in one of Professor 
Gibson's cases of old luxation. 
The accident may be suspected when, after reduction, the head of the bone 
has a tendency to slip from its articulating surface; and the suspicion will 
be further confirmed if, in addition to the tendency to a recurrence of the 
dislocation, crepitus can be developed. Extensive rupture of the capsular 
muscles will strongly resemble this fracture. But in rupture of the capsular 
muscles there will be no crepitus. 
The treatment will consist in immobilizing the joint and arm, by placing a 
stout pad in the axilla and securing the arm to the body with a Velpeau 
roller. 
Fracture and dislocation may occur simultaneously,-that is, the same force 
which displaces the bone may fracture it. In such cases the fracture is gen- 
erally in the neck of the humerus, near to its 
head. (Fig. 945.) 
The nature of this injury can be determined by 
finding that the head of the bone is not affected 
by the movements of the arm, and also by the 
presence of crepitus when the broken surfaces of 
the bone are rubbed together. 
The patient being etherized, the head of the 
bone should be pressed back into the glenoid 
cavity with the fingers, after which the fracture 
must be dressed in the manner directed for the 
treatment of a fracture through the surgical neck 
of the humerus. 
Compound dislocation.-In very rare instances, 
the head of the humerus, after escaping from the 
glenoid cavity, may be forced through the soft 
parts. If the vessels remain untorn and the head 
of the bone sound, the luxation should be re- 
duced and the wound closed. If the head of the bone is broken, it will be 
safer to remove it before replacing the humerus. 
When the axillary artery is torn, the limb should be amputated at the 
shoulder-joint. 
When I was in Vienna, a very unique specimen of a dislocated humerus 
was shown to me in the museum of the University. The head of the bone 
had been driven through an intercostal space into the cavity of the thorax, 
pushing before it the pleura. The history of the accident, I was informed, 
wTas not certainly known; but it was very evident that the patient had re- 
covered from the injury, as the repair between the walls of the chest and the 
bone was complete. Larrey, in speaking of this same specimen, says that 
he was informed by Professor Prochaska that the dislocation was produced 
by a fall upon the elbow while the arm was extended, and that the patient 
was a young man about sixteen, and lived to the age of thirty, dying from 
causes altogether unconnected with this injury. The most persistent efforts 
had been made to reduce the luxation, but without success. 
Fracture of the ribs.-Such a fracture may be produced eithei' by the 
heel of a boot against the chest, or by other counter-extending force; or 
the accident may follow the violence inducing the dislocation. Such frac- 
DISLOCATIONS. 
Fig. 945. 
Unreduced luxation of the hu- 
merus, with fracture in the neck of 
the bone. DISLOCATIONS OF THE BONES OF THE FOREARM. 
67 
tures explain the emphysema, first observed by Desault, which in rare in- 
stances has been noticed over the chest after a dislocation, and which is no 
doubt the result of a wound of the lung inflicted by a fragment of a broken 
rib. 
The treatment will not differ from that appropriate for fracture from ordi- 
nary causes. 
Simultaneous Luxation of both Humeri has been observed in a few in- 
stances. The displacement is generally produced by falling upon the hands 
when the arms are outstretched to protect the body from injury. Examples 
of this accident have been noticed by Van Buren, Cowper, Pardee, Geddings, 
Nathan Smith, Holmes, and others. The accident, in the case reported by 
N. Smith, occurred during a powerful convulsion. 
The reduction of these double dislocations is accomplished upon the same 
principle as that laid down for the management of the usual form of the 
scapulo-humeral displacement. 
Dislocation of the tendon of the biceps muscle is an injury which I have never 
witnessed independent of a luxation of the humerus. 
I am at a loss to conceive how such a displacement 
can take place, except as the result of pathological 
changes (as osteo-arthritisf of which Fig. 946 is a good 
illustration. 
Congenital Dislocations of the Humerus.-These 
rare luxations are not unfrequently associated with mal- 
formations in other joints. Only two varieties of the 
displacement have been noticed,-the subcoracoid and the 
subacromial,-which have been described by Mr. R. W. 
Smith in his work on Fractures. 
The symptoms of this luxation are the same as those 
which accompany subcoracoid and subspinous displace- 
ments of the bone arising from traumatic causes. There 
has been observed in the congenital dislocations a re- 
markable atrophy of the upper arm, while the forearm 
retains its natural size. 
As these abnormities co-exist with defective develop- 
ment of the articular ends of the bones constituting the 
joint, they do not, in most instances, admit of successful 
treatment. In one case, however, Gaillard* succeeded 
in permanently restoring the humerus to its articulating 
cavity. The patient was a girl sixteen years of age. 
Before the final efforts at reduction were made, the bone 
had been well loosened from its abnormal position by 
repeated manipulation. 
A case which was shown to me as one of congenital 
luxation of the humerus I decided to have been produced 
during a difficult labor, by the traction which was made 
on the arm to effect delivery. It is not improbable that 
such may have been the origin of other cases recorded as congenital dis- 
locations. 
DISLOCATIONS OF THE BONES OF THE FOREARM. 
Dislocations of one or both of the bones at the elbow-joint are not uncom- 
mon accidents. Considering the extent and complexity of the articulation, 
and the serious inconveniences which result from defective motion of the 
forearm, they demand a most careful consideration. 
These dislocations are most common during early life. Of 113 cases ad- 
mitted to the Pennsylvania Hospital, 51 were in boys under fifteen years of 
age, 24 occurred between the ages of fifteen and twenty-five years, 20 be- 
Fig. 946. 
Displacement of the head 
of the humerus, with de- 
struction of the tendon of 
the biceps muscle. From 
a specimen in the museum 
of the College of Phy- 
sicians, Philadelphia. 
® Memoires de 1'Academie de Medecine, 1841; Malgaigne, p. 569. 68 
DISLOCA TIONS. 
tween twenty and thirty-five years, 12 between thirty-five and forty-five, 
but only 6 after forty-five years. Of these dislocations, 105 were in males 
and 8 in females.* Professor Hamilton,! in an analysis of 60 cases, found 
the average age to be about twenty years. Of this entire number, 23 were 
in children under fourteen years of age. The statistics of the Middlesex 
Hospital, according to Holmes,! furnish 73 instances of elbow dislocations, 
48 of which occurred in children between five and fifteen years of age. At 
Guy's Hospital,§ the proportion of children has not been so great, only 6 
cases between ten and twenty having been reported. 
The dislocations of the bones of the forearm are as follows: 
First, dislocation of the radius from the humerus,-humero-radial,-some- 
times called radio-ulnar dislocation; second, dislocation of the ulna from 
the humerus,-humero-ulnar; third, dislocation of both the radius and the 
ulna from the humerus, frequently designated as a luxation of the elbow; and, 
fourth, dislocation of the inferior extremity of the ulna from the radius, 
often described as inferior radio-ulnar displacements. 
The head of the radius may be detached from the sigmoid cavity of the 
ulna and from the humerus, and be displaced in three different directions,- 
forward, backward, and outward. In these dislocations the lateral and an- 
nular ligaments are torn, and the head of the bone rests in front of, behind, 
or external to the external condyle of the humerus. 
The accident is very frequently overlooked; at least I have seen quite a 
number of unreduced luxations of this bone. 
Radio-Humeral Dislocations. 
Dislocation Forward.-This luxation is by far the most common. It may 
be produced by a fall upon the hand while the latter is in a state of forced 
pronation, by a force applied to the outer side of the elbow, or by the strug- 
gles of a child held by the hand and endeavoring to release itself from the 
grasp. 
Symptoms.-The radial side of the forearm is somewhat shortened and in- 
clined outward. A depression exists immediately below the external con- 
dyle of the humerus, being 
the vacated sigmoid cavity 
of the ulna. The head of 
the bone can be felt in 
front of the elbow (Fig. 
947), and may be recog- 
nized by its movements 
if the thumb is placed 
upon it while the forearm 
is supinated and pronated. 
The biceps muscle is re- 
laxed, as is the supinator, 
and hence the hand is found either in its natural position or slightly pronated. 
The forearm cannot be thoroughly extended, and flexion, when carried be- 
yond a certain angle, is suddenly arrested by the head of the radius striking 
against the front of the brachialis anticus. 
Treatment.-A little forcible flexion of the forearm being made in order 
to relax still more the biceps muscle, extension should be made from the hand, 
and counter-extension from the arm by the assistants, while the surgeon 
presses the head of the bone downward and outward towards the sigmoid 
cavity of the ulna, at the same time directing that the hand shall be pronated. 
If successful in effecting a reposition, it will require the utmost care to 
Fig. 947. 
Position of the head of the radius in an anterior luxation. 
* Alison's Manuscript Tables. 
t Hamilton on Fractures and Dislocations, 5th ed., p. 626. 
j Holmes's System of Surgery, vol. ii. p. 764. 
$ Bryant's Surgery, p. 725. RADIO-HUMERAL DISLOCATIONS. 
69 
prevent a recurrence of the displacement. The forearm must be maintained 
in the flexed position, at a right angle, by either an anterior or a posterior 
angular splint. This should be secured with a roller bandage, interposing, 
if necessary, a firm compress over the head of the radius. This dressing 
should not be removed for at least two weeks, unless there is reason to be- 
lieve that the bandage is too tight, or that excoriation exists. It will require 
at least two months before the ligaments shall have united sufficiently to give 
a reasonable security to the bone. 
The treatment of this luxation is, however, most unsatisfactory, even when 
the patient is seen immediately after the injury. Great difficulty will usually 
be experienced in effecting the reposition, or, if successful in this, in retaining 
the head in its normal position. 
After the bone has been out of place for a few days, in most instances, its 
reduction will be a matter of impossibility. Notwithstanding the irreduci- 
bility of the luxation, the usefulness of the limb is not materially impaired. 
The head of the radius soon establishes for itself an excavation in its new 
situation, in front of the brachialis anticus muscle, having the sphere of its 
movements circumscribed by a wall of condensed connective tissue, similar 
to a capsular ligament. The movements of extension, of pronation, and of 
supination can be readily executed; and even that of flexion is gradually 
increased by a partial absorption of the head of the bone. 
Partial dislocation of the radius forward may occur when the coronary 
ligament alone is torn. The treatment will be the same as in the complete 
luxation. 
Dislocation Backward.-In this displacement the head of the radius es- 
capes through a laceration in the posterior aspect of the capsular ligament, 
the coronary and oblique ligaments being also torn. The head of the bone 
rests behind the external condyle of the humerus. 
This accident is comparatively rare, there not being, according to Hamil- 
ton, more than about twenty-eight examples of the injury recorded. Ac- 
cording to Markoc, of New York, this dislocation is usually associated with 
a fracture of the internal condyle of the humerus. 
Causes.-This dislocation may either follow a blow in front of the head 
of the radius, or may be caused by a fall upon the hand when the bones 
of the arm are in a state of extreme pronation. It has also been produced 
in the act of wringing out clothes.-a movement involving very forcible 
pronation of the hands. 
Symptoms.-The forearm is found slightly flexed by the tension of the 
biceps; the hand is pronated, slightly flexed and fixed; supination is impos- 
sible ; a depression can be felt below the external condyle of the humerus, 
answering to the position of the sigmoid fossa. A hard round tumor can be 
discovered behind the condyle, 
which can be identified as the 
head of the bone, both by its 
form and by its movements, 
which correspond to those of 
the bones of the forearm. Both 
flexion and extension are 
greatly abridged. (Fig- 948.) 
Treatment.-An assistant 
makes counter-extension from 
the arm, while the surgeon, 
grasping the hand, makes ex- 
tension, followed by supina- 
tion, pressing at the same time the head of the bone forward towards its 
articulating cavity. After the reduction, the forearm and arm should be 
placed on an anterior angular splint, the angle being very obtuse, so as to give 
greater security to the reduction. 
Fig. 948. 
Position of the radius behind the external condyle in a posterior 
luxation. 70 
DISLOCATIONS. 
When the dislocation is conjoined with a fracture of the internal condyle, the 
same dressing will be indicated. 
Dislocation Outward.-The head of the bone, to occupy a locality directly 
outward, would have to rest upon the epicondyloid ridge,-a position so ex- 
tremely improbable that it is questionable whether such a dislocation, in the 
strict sense, evei- occurs. The head of the bone in an anterior displacement 
may rest on the flat surface of the humerus, immediately inside of the epi- 
condyloid ridge; and in this situation it resembles an external displacement, 
though it is in reality an anterior one. The interosseous ligament will prob- 
ably be detached at the upper extremity of the bones, so as to admit of their 
separation. 
Symptoms.-The signs of this presumptive dislocation are undue promi- 
nence above and a little in front of the external condyle of the humerus ; the 
forearm is fixed, placed between pronation and supination, neither of which 
motions can be executed, except with difficulty; and an unusually promi- 
nent line, corresponding to the upper fifth of the radius, is found on the 
outer aspect of the forearm. Flexion and extension, though much abridged, 
are not destroyed. 
Treatment.-This will consist in making extension and counter-extension 
while the arm is moderately flexed, and at the same time pressing the head 
of the bone downward and forward. The limb will require to be fixed in 
the same angular dressing as in the usual form of radio-ulnar displacements. 
Dislocation of the Ulna from the Humerus.-This luxation, though well 
established, is by no means a common accident. It consists in a posterior 
displacement of the ulna upon the humerus, the radius continuing to main- 
tain its functional position 
against the external con- 
dyle. The coronoid process 
slides back to the margin 
of the olecranon fossa, or it 
may rest on the posterior 
face of the internal condyle 
of the humerus. In either 
case the upper part of the 
interosseous ligament will 
be torn. (Fig. 949.) 
Dislocations of the Radius and Ulna.-This injury requires for its production 
a violent force applied to the hand while the forearm is flexed on the arm, 
and, in addition, some unusual twist affecting the relation of the bones in a 
manner which it is not easy to understand. 
The reduction is best accomplished by making extension and counter- 
extension around the knee placed in the bend of the arm. 
This luxation may take place in four directions,-backward, forward, out- 
ward, and inward. A variety of the last-named displacement may be termed 
poster o-later al. 
Dislocation Backward. - This is the most common displacement of the 
elbow-joint. It results from force concentrated on the articulation when the 
latter is in a vulnerable position,-as when an individual is dashed headlong 
from a vehicle and strikes upon the hands while the forearm is flexed upon 
the arm. It may also be produced by the limb being caught in the belting 
of machinery, in which it is wrenched, twisted, and bent in a manner so 
sudden and rapid as to defy any attempt at analyzing the order of the 
violence. 
In this displacement the anterior and lateral ligaments are torn, and the 
two bones, retaining their parallelism, slip behind the humerus; the coro- 
Fig. 949. 
Backward dislocation of the ulna. DISLOCATIONS OF THE RADIUS AND ULNA. 
71 
noid process of the ulna drops into the olecranon fossa of the humerus, and 
the radius occupies the posterior surface of the external condyle. The bra- 
chialis anticus muscle is rendered 
tense over the articular surface of 
the humerus, while the tendon of 
the biceps is only slightly stretched. 
(Fig. 950.) Both the median and 
ulnar nerves are exposed to press- 
ure. The ulnar and interosseous 
vessels may also be subjected to 
compression. 
It is not uniformly the case that 
the bones of the forearm are'placed 
as represented above. The coro- 
noid process of the ulna may, by 
the action of the triceps, be drawn 
above the olecranon fossa, or it may stop short of that cavity, the head of 
the radius preserving the relative level on the posterior surface of the 
humerus. 
Symptoms.-The signs of a 
posterior dislocation of the el- 
bow are very characteristic. 
The forearm is somewhat flexed 
on the arm and shortened ante- 
riorly; a prominence exists in 
front of the elbow, formed by 
the lower extremity of the hu- 
merus; and another prominence 
posteriorly, made by the olec- 
ranon process of the ulna and 
the tendon of the triceps mus- 
cle. (Fig. 951.) Flexion and 
extension of the forearm are, as 
a rule, made with difficulty, and 
the hand is, in consequence of 
the slight tension of the biceps 
tendon, frequently in a state of 
supination. 
Diagnosis.-Between dislo- 
cation of the elbow and supra- 
condyloid fracture of the hu- 
merus there are several features of resemblance. But the two injuries may 
be distinguished from each other by observing the following points: 
Fig. 950. 
Relation of the bones and muscles in a posterior dislocation 
of the bones of the forearm. 
Fig. 951. 
Appearance of the limb in a dislocation of the elbow. 
DISLOCATION OK THE ULNA AND RADIUS 
BACKWARD. 
Olecranon process is above the level of the in- 
ternal and external condyles of the humerus. 
Lower end of the anterior prominence smooth 
and rounded and broad, being the articular end 
of the humerus. 
Flexion and extension difficult, the forearm 
being rigid and fixed. 
The posterior projection is increased by flexion 
and diminished by extension. 
Reduction once effected by extension and 
counter-extension, the deformity permanently 
disappears. 
No crepitus. 
Forearm shortened anteriorly. 
FRACTURE ABOVE THE CONDYLES OF THE 
HUMERUS. 
Olecranon process is on a line with the internal 
and external condyles of the humerus. 
Lower end of the anterior prominence irreg- 
ular, probably spiculated, and not broad. 
Flexion and extension easy; forearm movable. 
Posterior projection diminished by flexion and 
increased by extension. 
Reduction easily accomplished by extension 
and counter-extension, but the deformity imme- 
diately reappears on the withdrawal of these 
forces. 
Crepitus. 
Forearm not. shortened anteriorly. 72 
DISLOCATIONS. 
If the summit of the olecranon process of the ulna and the internal and 
external condyles of the humerus are found to be on a line, the surgeon may 
confidently assert that there is no luxation of the bones of the forearm. 
Treatment.-The reposition of a luxated elbow is usually very easily ac- 
complished when brought early to the attention of the surgeon. But if it 
is not detected, or if allowed to remain even for a single week, the difficulties 
of reduction are immensely increased ; and often, after the lapse of four or 
five weeks, they become insurmountable. The practitioner is not, however, 
to decline making an attempt to restore a displacement of this articulation, 
even after a much longer period has passed than the one just mentioned. 
Numerous instances are recorded in which old dislocations of this joint have 
been successfully treated by Sir Astley Cooper, Malgaigne, Boux, and others. 
Brainerd, of Chicago, reduced a luxation of the elbow-joint of five months' 
standing; Westmoreland, of Georgia, one after the same length of time; 
Gerdy and Drake each one of six, and Hamilton one of seven, months' stand- 
ing. Among the number of these old luxations collected by Denuce is one 
which is said to have been reduced by Starch two years and one month aftei- 
the accident. I have succeeded, in two instances, in replacing a dislocation 
of these bones, one after four and one after 
six weeks, with almost as much facility as 
if the attempt had been made a few days 
after the injury. 
In cases of luxation at the elbow where 
difficulty is anticipated, an anaesthetic 
should be given prior to the employ- 
ment of any measure for reduction. Dif- 
ferent methods are employed to reduce 
this luxation. That adopted by Sir Astley 
Cooper will be found to succeed perfectly 
well for recent cases. It is to seat the pa- 
tient on a stool or a chair, while the surgeon, 
placing his foot on the same and planting 
his knee on the inner side of the elbow, 
seizes the injured limb at the wrist with 
both hands and bends the forearm forcibly 
around his leg. (Fig. 952.) The main ob- 
ject is to lift the coronoid process out of the 
olecranon fossa, when it will be drawn into 
place by the brachialis anticus muscle. 
The knee, in order to fulfill this indication, 
should be so placed against the bend of the 
elbow that, while it firmly fixes the hu- 
merus, its inner side can be used as a ful- 
crum for the radius and ulna, and thereby 
enable the operator not only to raise the 
coronoid process, but also at the same time to separate the bones of the arm 
and the forearm, and thus remove all impediments to the reposition. 
Professor Gross adopts a plan which is equally efficient with that of 
Sir Astley Cooper. The surgeon, carrying his limb across the body of the 
patient, places his foot in the bend of the arm, and makes extension from 
the wrist. 
The arm has, in some cases, been bent round a bedpost, with the effect of 
quickly reducing the dislocation. 
Dorsey's plan, which is a very good one, consisted in having extension and 
counter-extension made, while the surgeon, locking the fingers of the two 
hands over the inner surface of the bend of the elbow, and placing the two 
thumbs against the olecranon process, forced the latter downward, at the 
same time drawing the elbow backward so as to increase the flexion of the 
arm. 
Fig. 952. 
Reduction of a dislocated elbow with the knee 
in the bend of the arm. DISLOCATIONS OF THE RADIUS AND ULNA. 
73 
Instead of flexion, forcible extension of the arm has been used with success 
by Waterman. In adopting this mode of reduction, the forearm must be for- 
cibly extended. By this movement, the ulna becomes a lever of the third 
kind. Its fulcrum, at the extremity of the olecranon process, is forced against 
the posterior surface of the humerus. And in this manner the coronoid is 
lifted out of the olecranon fossa, when, by making extension and counter- 
extension, it is dragged over the trochlear surface of the humerus into its 
proper position, by the contraction of the brachialis anticus muscle. In cases 
demanding the use of much force, as in old luxations, extension and counter- 
extension must be made by bands attached to the forearm and the arm and 
committed to assistants to pull upon. If a more steady and a greater amount 
of power is required, to the extending bands should be attached the compound 
pulley. While these forces are being exerted, the surgeon must, by means 
of a folded sheet placed round the elbow, draw the latter directly backward, 
or at a right angle with the extending and counter-extending forces. Or he 
may, after the manner of Dorsey, accomplish the flexion with his hands, at 
the same time pressing with his thumb the olecranon process downward. 
Crosby, of New Hampshire, in two cases, succeeded in replacing old luxations 
of the elbow, after fracturing the olecranon process in bending the arm. 
Mussey, of Cincinnati, was also able to reduce one case, and Hamilton three 
cases, by the same procedure. The same plan has been adopted by Professor 
Gross, with a satisfactory result. 
Hamilton, in an obstinate case of an old dislocation of the elbow backward, 
effected the reposition, after dividing the tendon of the triceps muscle sub- 
cutaneously. 
The suggestion to divide through the interior of the joint whatever may 
oppose the restoration of the bones may in old luxations, by wounding vessels 
and nerves, be followed by graver evils than the disability it is proposed to 
remedy. 
Notwithstanding that it has been possible occasionally to overcome all dif- 
ficulties and return the bones to their true functional position, these triumphs, 
when compared with the many failures, are highly exceptional, and have not 
unfrequently been won at the cost of a ruptured brachial artery, the lacera- 
tion of an important nerve, the induction of gangrene, the loss of an arm, 
and even, as in Velpeau's patient, of life itself. In consideration of these 
facts, I am prepared to condemn all persistent attempts to reduce, by ex- 
traordinary force, old luxations of the elbow-joint. 
It will be wiser to fracture the olecranon, and by regularly-enforced motion 
to restore, in this way, the usefulness of the limb. The operation is easily 
executed by perforating the base of the process at two or three points with 
a fine drill, and afterwards breaking it away from the upper end of the shaft 
of the bone by forced flexion of the arm. 
In reduction, the return of the bones to theii' proper place is generally an- 
nounced by a slip, or a sound which is quite characteristic. The deformity 
disappears, the true rectilinear relation of the olecranon process and the con- 
dyles of the humerus is re-established, and the forearm can, without resist- 
ance, be flexed to a right angle with the arm. The last two signs of a suc- 
cessful reduction should be carefully noted. If one is absent, the other will 
be absent also; and when this is found to be the case, the surgeon may rest 
assured that the reposition is not complete. 
After the bones have been replaced, it will be necessary to combat the 
secondary inflammation by the application of lead-water and laudanum, 01* 
by the use of ice-bags around the joint. To guard against the recurrence of 
the dislocation by any careless movements of the arm, an angular splint may 
be loosely attached to the anterior surface of the limb. In a docile, intelligent 
patient the splint is not necessary, only requiring that the arm be supported 
on a pillow or in a sling. After six or seven days, when the inflammation is 
on the decline, careful movements of the articulation must be commenced in 
order to prevent stiffness. 74 
DISLOCATIONS. 
Complications.-The complications which may possibly accompany luxation 
of the elbow are supra-condyloid fracture of the humerus, fracture of one of 
the condyles,-generally the internal,-and fracture of the olecranon or of 
the coronoid process of the ulna. 
The signs of a supra-condyloid fracture have already been noticed. 
When a condyle is detached, it can be recognized by the presence of unusual 
mobility, and by crepitus. 
Fracture of the olecranon can be discovered by grasping the process between 
the thumb and fingers and finding its movements to be entirely independent 
of those of the ulna. 
Fracture of the coronoid process-a rare occurrence-is indicated when, 
after reduction, there is a constant tendency to displacement, and, perhaps, 
by the presence of crepitus. 
All of these injuries complicate the dislocation more or less by increasing 
the risk of anchylosis or of defective movements in the joint. 
When the olecranon has been broken, it will be necessary, in order to bring 
the detached process into proximity with the shaft of the bone, to place the 
limb in a moderately extended position, and, to prevent the triceps muscle 
from drawing the fragment upward, the middle of a long strip of adhesive 
plaster should be applied above the process. The ends of the strip, being 
drawn downward and forward, can be secured by first crossing them in 
front below the elbow, and conducting them again to the back of the forearm, 
where they are to be fastened. A splint with a very obtuse angle, secured 
to the front of the limb, will complete the dressing. 
A like plan of treatment will answer when there is reason to believe that 
the coronoid process has been broken. 
When the fracture is supra-condyloid or condyloid, two angular splints 
should be used,-a flat one for the anterior and a concave one for the posterior 
aspect of the limb. 
Dislocation Forward. - In looking at a ligamentous preparation of an 
elbow-joint, independent of clinical experience, it would seem to be impossible 
that a dislocation of the bones of the forearm forward could take place 
without a precedent fracture of the olecranon process. Several examples, 
however, have been observed in which the signs were so entirely corrobora- 
tive of the accident that little doubt of its reality can remain. Colston, 
Lana, and Delpech each claim to have witnessed the accident. Dr. Forbes, 
of Philadelphia, met with one case of the injury; Hunt, of Chicago, another; 
and six other cases are recorded by Hamilton, viz., those of Monin, Prior, 
Velpeau, Canton, Denuce, and Longmore of London. 
This dislocation may be complete or partial. 
To effect such a displacement without a frac- 
ture of the olecranon process must necessarily 
require that the forearm be carried very much 
off in a lateral direction, and afterwards sub- 
jected to a violent twist, the olecranon not 
coming directly forward, but describing, in a 
lateral direction, the segment of a circle. 
Symptoms.-When the dislocation is complete, 
the radius and ulna occupy a position in front 
of the humerus, the head of the radius resting 
on the coronoid fossa, or lying a little to its 
outer margin; the posterior face of the ulna 
then lies in contact with the front of the inner 
condyle, or on the inner side of the coronoid 
fossa. (Fig. 953.) The arm is shortened and 
Hexed. The broad, rounded surface of the hu- 
merus will be felt posteriorly, with the olecranon process and the head of 
the radius. The latter may be recognized by its movements under the 
Fig. 953. 
Anterior dislocation of both bones of the 
forearm. LATERAL DISLOCATIONS OF THE FOREARM. 
75 
thumb, when the hand is greatly pronated and supinated. The sigmoid 
cavity may also be distinguished. 
When the dislocation is partial or incomplete, the extremity of the olecra- 
non process rests upon the lower end of the articulating surface of the 
humerus. In this case the forearm is lengthened and somewhat flexed. 
Treatment. - When the luxation is complete, it must be reduced by 
making forced flexion of the forearm. If this plan alone fails, it may be 
tried again conjointly with extension made from the wrist and counter- 
extension by the foot or by bands from the arm. 
When the dislocation is partial, the reposition can be accomplished by 
forcing the arm forward and the forearm backward while extension and 
counter-extension are being made. 
Lateral Dislocations.-These displacements may occur in two directions,- 
outward and inward. The first is'the more frequent form, though either must 
be regarded as a very unusual accident. 
These dislocations, with few exceptions, are incomplete. They are caused 
by violence acting on the upper and lower arm in opposite directions, as when 
the limb is wedged between the spokes of a wheel and the side of a wagon, 
or when, in heavy falls, the resistance of the ground on the hand and the 
weight and momentum of the body are received when the limb is in a posi- 
tion favorable to the expenditure of the force upon the lateral ligaments of 
the joint. 
Symptoms.-When the dislocation is incomplete and outward, the ulna is 
not entirely removed from the trochlear surface of the humerus. But it is 
shifted to its external side, resting partly upon the external condyle. And 
the same is true of the radius, provided the determining force has not rup- 
tured the coronary ligament. The head of the bone either remains in contact 
with the outer margin of the radial surface of the humerus, or rests between 
the latter and the epicondyloid eminence. (Fig- 954.) 
Where the displacement approaches more nearly to the complete form, the 
radius will be carried entirely clear of, and external to, the external condyle, 
while its articulating surface on the humerus will be occupied by the sigmoid 
cavity of the ulna. A more extensive laceration of the radio-ulnar ligaments 
may destroy the parallelism between the radius and the ulna, allowing the 
head of the former bone to occupy a plane either anterior or posterior to the 
ulna. These changes in the relations of the bones of the forearm and arm 
give rise to the following symptoms, namely, a variable degree of flexibility 
of the forearm, a marked projection on the inside of the elbow, made by the 
internal condyle of the humerus, and a lesser prominence posteriorly, formed 
by the olecranon process of the ulna. On the outer side of the articulation 
the head of the radius will be apparent. By rotating the bone, it can be 
seen and felt to move underneath the integument. (Fig. 955.) 
In the inward dislocation, rarer than the one just described, and always 
incomplete, the ulna rides the internal condyle, and the head of the radius 
rests in one of three positions, viz., against the lower surface of the trochlea 
of the humerus, normally occupied by the great sigmoid cavity of the ulna, 
or slightly on either its anterior or posterior face. (Fig. 956.) 
Should the ulna be displaced behind the internal condyle of the humerus, 
the head of the radius will slip back into the olecranon cavity, forming a 
postero-lateral dislocation. 1 
Symptoms.-The arm is flexed, inclines inward, and is shortened along 
its ulnar border. The internal condyle becomes indistinguishable by the pro- 
jection of the olecranon process of the ulna. The external condyle is rendered 
unusually conspicuous by the absence of the head of the radius from its 
capitulum. And the hand is pronated by the tension made upon the pronator 
radii teres muscle. 
In the postero-lateral luxation, in addition to the prominence made by the 
external condyle of the humerus, the arm will be shortened anteriorly; and 76 
DISLOCATIONS. 
the projection of the olecranon process of the ulna will be felt immediately 
behind the external condyle of the humerus. 
Treatment.-The reduction of the outward and inward luxations is effected 
Fig. 954. 
Fig. 955. 
Fig. 956. 
Outward dislocation of the 
forearm. 
Deformity in outward dislocation 
of the forearm. 
Inward dislocation of 
the forearm. 
by grasping the forearm with one hand and the arm with the other, neai' to 
the elbow, and, while extension and counter-extension are being made, by 
forcing the humerus and the bones of the lower arm in opposite directions. 
The postero-lateral luxation should be treated as a posterior dislocation, by 
bending the front of the elbow around the knee, or by flexion and extension, 
conjoined with lateral pressure. 
1 have never witnessed a dislocation of this nature, and therefore have 
no experience of the difficulties attending its reduction. Malgaigne, who 
appears to have seen four cases of the injury, was unable to replace a single 
one. 
Compound Dislocations of the Elbow. 
Of 113 dislocations of the elbow treated in the Pennsylvania Hospital, 4 
were compound. Though exceedingly grave injuries, they do not necessarily 
cause the loss of the arm. The only circumstances which will justify a resort 
to amputation are lacerations of the principal blood-vessel, or extensive frac- 
tures of the bones, with wide-spread mutilation of the soft tissues. 
In the absence of these, there are two plans of treatment open to the sur- 
geon's choice. The first is to replace the bones, to close the wound, and to 
moderate as much as possible the resulting inflammation and suppuration; 
the second, to make a partial or complete resection of the bones, and after- 
wards proceed as in the first method. 
I have practiced both plans, but give a decided preference to partial resection. 
When the opposite plan is pursued, the muscular tension, pain, and spasm 
which attend the ensuing inflammation give rise not only to severe constitu- 
tional disturbance, but to diffuse abscess, which is likely to prove ruinous to 
the structures of the entire limb. These dangers were well known to the 
ancient surgeons, some of whom advised non-reduction, and most amputation. 
It will, therefore, greatly contribute to the success of a case of compound COMPOUND DISLOCATIONS OF THE ELBOW. 
77 
luxation of an elbow-joint to remove the projecting ends of the ulna and 
radius, so that they can be readily replaced and will lie easy and free from 
all pressure within the wound. 
The operation and dressing should be conducted under the carbolic acid 
spray, accompanied with all the details of the antiseptic treatment. 
Dislocation of the Inferior Radio-Ulnar Articulation.-In this dislocation 
the lower extremity of the ulna is separated from the semilunar cavity of 
the radius, and may be displaced in two directions, viz., backward or for- 
ward. The former is slightly the more common of the two. These lux- 
ations rarely occur independent of a fracture of the radius. There is an 
incomplete or partial form of this displacement which I have observed in a 
number of instances. 
Backward Dislocation is the result of extreme and violent pronation of 
the hand. It may also follow a comminuted fracture at the carpal extremity 
of the radius. The posterior radio-ulnar and the sacciform ligaments will be 
ruptured, and the triangular interartieular cartilage disconnected at its apex 
from the root of the styloid process of the ulna. 
Symptoms.-The signs of the injury are the following: a marked and 
movable prominence at the back of the wrist at its outer border, either 
rising above the plane of the radius or crossing in front of the latter; the 
'styloid process is no longer in line with the fifth metacarpal bone ; a cord- 
the tendon of the extensor carpi ulnaris-may be seen, over which the skin 
is stretched, rising from the lower fifth of the ulna and descending towards 
the metacarpal bone of the little finger; the hand is in a state of pronation, 
and the fingers are somewhat flexed. 
Treatment.-The hand must be extended, in order to relax the extensor 
carpi ulnaris muscle; and the end of the bone at the same time should be 
pressed directly backward into its semilunar cavity. After the reduction, 
the tendency to reluxation can only be prevented-especially when the 
laceration of the ligament has been extensive-by the use of a Bond's splint 
and a firm compress bound over the posterior surface of the bone. Even 
after the removal of the splint, which should not be earlier than four weeks, 
it will be a wise precaution to substitute in its place an elastic armlet, to be 
worn for three or four months, or until the repair of the ligaments of the 
joint has been completed. 
Dislocation Forward.-The dislocation forward demands for its production 
a violent supination of the hand, by which the rounded surface of the ulna is 
pressed strongly against the anterior ligaments of the joint and ruptures them. 
The statistics of the anterior dislocation of the ulna, collected by Malgaigne 
and by Hamilton, prove the injury to be almost as common as the displace- 
ment backward. 
Symptoms.-An unusual projection is seen immediately above the hand and 
somewhat across the face of the radius, where it is drawn by the pronator 
quadratus muscle; on the back of the wrist the usual rotundity of the lower 
end of the ulna is absent; the hand is supinated and the fingers are flexed. 
Treatment.-The reduction is performed by first flexing the forearm, and 
then, while making at the same time extension from the hand, counter- 
extension from the arm, and forced pronation, by pressing the hemispherical 
head of the ulna back towards the semilunar cavity of the radius. 
The subsequent dressing should consist of two flat, well-padded, plain 
splints, secured to the limb by a roller, and extending the anterior one from 
the bend of the elbow to the extremities of the fingers, and the posterior 
one to the carpus. 
Partial Luxation.-This displacement is sometimes met with after severe 
twists of the wrist, or, more commonly, after badly-treated fractures at the 78 
DISLOCATIONS. 
lower end of the radius, leaving the hand in a state of abduction. Under 
such Circumstances, from the strain to which the inferior radio-ulnar liga- 
ments may have been subjected at the time of the accident, causing a rup- 
ture of some of their fibres, or from the continued tension exerted on the 
articulation by the malposition of the hand, the sacciform and other ligaments 
become expanded or elongated, so as imperfectly to confine the head of the 
ulna in place. 
Symptoms.-This condition may be recognized by the unusual external and 
posterior prominence of the lower end of the ulna, by the great mobility of 
the same, and by the weakness of the wrist which exists. 
Treatment.-The displacement is irremediable, consequently the treat- 
ment must be one of palliation. A strip of muslin or of flannel bound firmly 
about the wrist gives the best protection to the joint. 
DISLOCATIONS OF THE HAND. 
Dislocations of the hand include those of the carpus, the metacarpus, and 
the phalanges. 
Dislocations of the Carpus. 
Nothing perhaps more conspicuously exhibits the accuracy with which the 
investigation of surgical injuries has been pursued than the surgery of wrist 
dislocations. Among the older surgeons these luxations were regarded as 
very common accidents. It was only after Poteau called attention to the 
peculiarities of fractures at the lower end of the radius that the occurrence 
of these so-called carpal dislocations began to be challenged. Dupuytren 
barely admitted the possibility of the injury. Desault also had expressed 
the opinion that fractures at the wrist were often mistaken for luxations. 
The cases of carpal dislocation, uncomplicated by fracture, which have been 
verified by dissection are so few that it must be regarded as an injury of ex- 
ceedingly rare occurrence. The power of the radio-carpal joint to escape 
dislocations arises from the resistance of the strong ligaments, the numerous 
flexor and extensor tendons (which run ovei* the anterior and posterior 
aspects of the joint) being confined in their places by the anterior carpal 
ligament in front, and by the osteo-fibrous canals on the back of the wrist. 
To these peculiarities of anatomical structure must be added the liability to 
fracture of the lower extremity of the radius from the manner in which the 
carpus is impelled against or bent upon the end of the bone in the reception 
of ordinary injuries, when the force is transmitted from the hand to the 
wrist-joint. The concavity (between the styloid process of the radius and 
that of the ulna) for the reception of the scaphoid, semilunar, and cuneiform 
bones of the carpus is so deep, and the lateral ligaments so strong, that a luxa- 
tion of the carpus must be backward or forward. A lateral luxation would 
only be possible after a fracture of one or the other of the styloid processes. 
Dislocation Backward.-This displacement may follow the application of 
force to the back of the hand, in consequence of which the latter is flexed to 
a degree which results in the rupture of the posterior radio-carpal and lateral 
ligaments, and in the detachment of the fibrous arches over the grooves on 
the back of the radius, thus allowing the carpus to be lodged on the posterior 
surfaces of the radius and ulna. (Fig. 957.) 
Symptoms.-One sign of a dislocation of the carpus backward is the great 
thickness in the antero-posterior diameter of the wrist, the upper end of the 
dorsal prominence being the rounded surface of the carpus, and the lower 
end of the palmar prominence being the broad and less regular extremities of 
the radius and ulna, the styloid processes of which may be felt. The hand 
also will be a little extended, the fingers flexed, and the forearm shortened. 
(Fig. 958.) DISLOCATIONS OF THE CARPUS. 
79 
Treatment.-Grasping the hand of the patient, palm to palm, extension 
should be made, the surgeon at the same time imparting a lever-like motion 
Fig. 957. 
Fig. 958. 
Dislocation of the carpus backward. 
Deformity after a backward disloca- 
tion of the carpus. 
to the carpus,-that is, by making slight flexion, extension, abduction, and 
adduction. 
A sudden slip and the disappearance of the deformity, without any tend- 
ency to its return when the extending force is removed, are the indications 
that the reduction has been complete. 
Dislocation Forward.-In this variety of the injury the anterior radio- 
carpal and some fibres of the lateral ligaments are torn, and the bones of the 
carpus occupy the anterior surface of the radius. (Fig. 9G0.) 
Fig. 959. 
Fig. 960. 
Deformities after anterior'dislocation of the carpus. 
Anterior dislocation of the carpus. 
Symptoms.-This luxation is known by the peculiar prominences at the 
wrist, the posterior being more marked and less regular than the anterior. 
The arm is shortened, and the hand and fingers are extended. 
Treatment.-The reduction is effected by making traction from the hand, 
as in the preceding dislocation. At the same time, the carpus is extended 
upon the arm, and the anterior or carpal prominence is pressed downward. 
After the reposition, the articulation should be enveloped in a lotion of 
lead-water and laudanum, and be supported for six or eight days on a Boston 
splint. As soon as the inflammatory swelling begins to subside, passive 
motion must be commenced, with a view to prevent anchylosis of the joint. 80 
DI SLOG A TIONS. 
Diagnosis of Carpal Luxations.-The fact that fractures at the lower 
extremity of the radius are often diagnosed as carpal luxations constitutes a 
sufficient reason, before dismissing the subject, for noticing the general points 
of distinction. In luxation, the deformity, both dorsal and palmar, is much 
more marked than in fracture. In luxation, the hand is not deflected either to 
the right or to the left, while in fracture it is frequently inclined to the radial 
side of the arm. Except when conjoined with fracture, there is, in disloca- 
tion of the carpus, no crepitus. When the reduction is made in a luxation of 
the carpus and the extension removed, there is at once the disappearance of 
all deformity, and without any tendency to its reproduction. In dislocation, 
the reduction, when it does occur, is a sudden event,-it is announced by 
a significant slip. Finally, in fracture, the fragments resume their proper 
relations more gradually, requiring a certain amount of coaxing and 
pressure. 
Treatment.-When the dislocation is accompanied with fracture at the 
end of the radius, it must be treated on the same principle as a like compli- 
cation elsewhere, namely, by restoring the luxation and then setting the 
fracture. 
Compound Dislocations of the Carpus.-An accident of this nature must be 
regarded as a very serious occurrence. It is necessarily rendered so by the 
disturbance to which so many tendons and their synovial sheaths are sub- 
jected ; by the extent of the articulation; and by the exposure to injury of 
so great a number of blood-vessels and nerves. 
Nevertheless, of such transcendent importance is the hand, that under no 
circumstances should it be sacrificed so long as there remains ground on 
which to build even the faintest hope of its preservation. The concomitant 
damage sustained by the parts must therefore determine the course of the 
surgeon in treating compound luxation of the wrist. 
As long as the principal blood-vessels and nerves remain intact, even 
although the soft parts be extensively mutilated and the articulating ex- 
tremities of the bones be comminuted, an attempt ought to be made to save 
the hand. 
After a complete excision of the damaged bones, the parts should be re- 
placed, a drainage-tube introduced, and the sides of the wounds loosely 
approximated. If the antiseptic plan of dressing is not adopted, the joint, 
after being placed upon a properly-padded splint, which must include also 
the arm and the hand, should be kept under an irrigating lotion of tepid 
water, medicated with a little laudanum. 
If the parts become swollen and painful, or if the suppuration becomes 
profuse, very great relief will be experienced by enveloping the lower part 
of the arm, the wrist, and the hand in a warm flaxseed-meal poultice, renewing 
the same three or four times in the twenty-four hours. 
When, in addition to the luxation, the bones are ground into fragments, 
the tendons lacerated and displaced, the chief vessels and nerves torn, and 
the other soft tissues disorganized, nothing remains but to cut off the dam- 
aged member ; it is irretrievably lost. 
Congenital Dislocations of the Carpus have been studied by Guerin, 
Cruveilhier, R. W. Smith, and R. Adams, of Dublin. Three forms of this 
dislocation are described, namely, the backward, the forward, and the back- 
ward and outward. 
In congenital dislocations all the components forming the articulation have 
been arrested in their development, and they are not unfrequently associated 
with other structural imperfections, or with monstrosities. 
The treatment of these luxations is very unsatisfactory. But enough has 
been ascertained to encourage a hope that, in selected cases, if the bones can 
be kept in position by mechanical means for a long time, the development of 
the articulation and of the muscles which surround it will in some measure 
correct the defect. DISLOCATIONS OF THE CARPAL BONES. 
81 
Dislocations of the Carpal Bones. 
It is difficult to conceive of a more compact and securely-constructed asso- 
ciation of bones than that constituting the carpus. Their numerous artic- 
ulating facets and their powerful interlacing ligaments bind together the 
different pieces so solidly that the displacement of any single bone is an 
event of very rare occurrence. When it does take place, it is usually accom- 
panied with other lesions, which not unfrequently result in the loss of the 
hand. 
The concave form of the palmar surface of the carpus, and the presence of 
the anterior annular ligament, resisting its expansion, are inimical to an an- 
terior displacement of the bones. Accordingly, when a luxation of any one 
of the carpal pieces happens, it is usually posteriorly, or towards the dorsal 
aspect of the hand. There are, I believe, but two instances to the contrary 
on record, namely, the case mentioned by Taafe, of Brighton, in which he 
states that the semilunar bone was displaced anteriorly, and a case occurring 
in the practice of Professor Chisolm, of Baltimore. 
The bones most liable to dislocation are the os magnum, the semilunar, 
and the pisiform, and for reasons not difficult to understand. If, in a liga- 
mentous preparation, the two rows of the carpus be partly separated, and 
if, in addition, the trapezium and the trapezoid on the radial side and the 
unciform on the ulnar side be detached from the os magnum, it will be seen 
that the last-named bone lies like a ball in a socket. The unciform and 
the pisiform, being on the outer limits of the first row, and comparatively 
superficial anteriorly, are necessarily exposed to injury. Moreover, the at- 
tachment of the tendon of the flexor carpi ulnaris to the pisiform renders it 
subject to dislocation by muscular action. 
Dislocation of the Os Magnum.-Cases of backward luxation of the 
os magnum have been noticed by Boyer, Chopart, Sir Astley Cooper, and 
Bransby Cooper. Richerand mentions the case of a female in whom this 
bone was displaced during a severe labor-pain, while the woman was forcibly 
squeezing the mattress with her hand. Bryant states that he has known a 
similar dislocation to occur during the throes of parturition, while the patient 
was grasping a towel. 
The signs of a luxation of the os magnum are so characteristic as to 
leave no room for mistake. A hard prominence is seen immediately behind 
the carpal extremity of the third metacarpal bone. As the luxation is never 
complete, there will usually be little difficulty experienced in pressing the 
bone back into its place. Some difficulty will be encountered in keeping it 
reduced, as in closing and flexing the hand the displacement is readily 
reproduced. Bransby Cooper reports the case of a patient at Guy's Hos- 
pital who was able to displace the bone at pleasure, an experiment which 
he frequently practiced for the benefit of the house surgeons. 
After the reduction, the hand should be placed in a palmar splint, keeping 
the fingers extended, and interposing a compress between the bone and the 
roller which secures the splint to the hand and arm. 
Dislocation of the Semilunar Bone.-A few examples of this luxation 
have been noticed. Erich sen met with one at the University Hospital, 
London. Bryant describes a specimen of this dislocation (compound) on 
both sides, -which is in the museum of St. George's Hospital. The injury in 
this case had been caused by a fall upon the hands, and the bones were 
displaced through the wounds in front of the wrists. 
The presence, after a fall upon the hands, of a hard body, semilunar in its 
form, on a line with the metacarpal bone of the index finger, and immediately 
below the posterior margin of the carpal extremity of the radius, is the sign 
which declares this luxation. 
The reduction is performed by making extension from the hand, and pressing 
the bone forward and upward. Though the disposition to reluxation is not 
quite so great as in the luxation of the os magnum, the same precautions 
VOL. II.-6 82 
DISLOCATIONS. 
must be observed-resting the articulation upon a palmar splint, etc.-as in 
similar injuries of the latter bone. 
Dislocations of the Pisiform Bone.-South, Ferguson, Erichsen, and 
Gras have each had a case of this luxation. The displacement appears to 
have been produced by the forcible action of the flexor carpi ulnaris muscle 
while lifting a heavy weight. 
The bone, when detached from the facet of the cuneiform bone, will be 
drawn up above the wrist; and it can be recognized as a a hard but movable 
prominence in front of the arm. 
Though it is extremely improbable that the bone can be retained in its 
normal situation, it should nevertheless be kept as near as possible to that 
point. To accomplish this, the pisiform must be drawn downward, the carpus 
being bent anteriorly upon the arm, in order to relax the flexor carpi ulnaris 
muscle and thus to favor the re-adjustment. A compress should be laid across 
the wrist, immediately above the bone, and made fast by a few circular and 
figure-of-eight turns with a narrow roller. After this the hand must be kept 
flexed by a humero-carpal handkerchief. 
I am not cognizant of any recorded example of a simple dislocation of the 
cuneiform or the unciform bone. 
Maisonneuve has reported, in the second volume of the " Memoirs of the 
Chirurgical Society," one case in which the second row of carpal bones was 
displaced posteriorly from the first row. The patient died from the effects of 
other injuries received at the time of the luxation. 
Dislocations of the Metacarpus. 
The only example of a displacement of all the metacarpal bones from the 
carpus of which I have any knowledge is one given by Erichsen and taken 
from a cast in the University College Museum. The 
displacement was forward. (Fig. 961.) 
Hamilton gives a case in which all the metacarpal 
bones, except that of the thumb, had been displaced 
backward. The patient at the time of the accident 
was a corporal in the United States army at Freder- 
icksburg, and the dislocation was produced by a ball 
that entered at the ulnar border of the hand and 
emerged at its radial border, issuing between the bones 
and the skin. The bones had not been reduced, but 
when seen four years after the injury the motions of 
the fingers (except the index and little fingers) were 
not impaired. The same author records two examples 
which came under his notice of posterior dislocations 
of the carpal extremity of the metacarpal bones of the 
index and middle fingers. In neither of these cases 
had the dislocation been reduced. 
Dislocation of the Metacarpal Bone of the 
Thumb.-This dislocation may take place in either 
of two directions,-backward or forward. It may be 
either partial or complete. The backward displace- 
ment is the more common of the two. It is produced 
by force applied to the anterior extremity of the metacarpal bone, causing 
extreme flexion; or it may be produced by a fall in which the weight of 
the body is received on the ball of the thumb. 
The signs of the displacement are foreshortening of the thumb, a promi- 
nence below the styloid process of the radius (formed by the carpal extremity 
of the metacarpal bone resting upon the trapezium), and an inclination of 
the thumb towards the palm of the hand, due to a slight tension of the first 
dorsal interosseous muscle. 
Treatment.-The reduction is effected by the surgeon grasping the pha- 
Fig. 961. 
Forward dislocation of the 
metacarpus. DISLOCATION OF THE THUMB. 
83 
langeal part of the thumb and simultaneously pressing the carpal extremity 
of the metacarpal bone downward and forward, while an assistant makes 
counter-extension from the wrist. If greater force is required than that which 
can be exerted by seizing the thumb, the Indian puzzle or the noose may be 
employed. 
The greatest difficulty has sometimes been experienced in repressing the 
tendency to reluxation. To prevent this, a plaster roller applied as a spica 
of the thumb, or a piece of light binders' board, softened in hot water and 
moulded accurately to the thenar and dorsal portions of the thumb, including 
also its phalangeal part, can be used with advantage. 
Dislocation of the Thumb. 
The phalanges of the thumb and of the fingers may be dislocated from 
their corresponding metacarpal bones {metacarpophalangeal luxations); or 
they may be displaced from one another {phalangeal dislocations). 
Dislocation of the Proximal Phalanx of the Thumb.-This is the 
most common of the metacarpo-phalangeal luxations. The displacement can 
occur in two directions,-backward and forward,-though the backward is 
much the more common form in which it happens. 
The Backward Dislocation of the First Phalanx of the Thumb is deter- 
mined by a blow or a fall in which the force is applied to, or the weight of 
the body received upon, the last phalanx while the latter is in a state of 
flexion, thus impelling the proximal phalanx backward and upward, and 
depositing it upon the dorsal 
surface of the metacarpal bone. 
(Fig. 962.) 
The ensuing deformity is 
very striking. The thumb is 
shortened and twisted inward; 
the ungual phalanx is flexed 
by the tension of the tendon of 
the flexor longus pollicis mus- 
cle ; the proximal phalanx is 
fixed, and two prominences are seen at the metacarpo-phalangeal joint. The 
one on the posterior and outer surface of the metacarpal bone is the larger 
of the two, and is the head of the proximal phalanx, while the smaller prom- 
inence on the anterior or palmar surface of the 
thumb is the distal end of the metacarpal bone. 
(Fig. 963.) 
The difficulties which have attended the re- 
duction of this dislocation render it necessary 
briefly to consider its pathology. Hey sup- 
posed that the chief obstacle to the reposition 
was the entanglement of the displaced phalanx 
between the lateral ligaments of the joint. And 
such was Dupuytren's opinion. The explana- 
tion given by Mr. Laurie* locates the difficulty 
in the anterior ligament, which, with the ses- 
amoid nodules, is carried back with the prox- 
imal phalanx and lodged between the articulating surface of the latter and that 
of the metacarpal bone. The same view was entertained by M. Paillaux.f 
Others, as Ballingall and Fabbri, believe that the explanation must be 
sought for in the manner in which the neck of the metacarpal bone is 
grasped by the two portions of the short flexor of the thumb. Hamilton 
is of this last opinion. After producing the luxation on the cadaver and 
Fig. 962. 
Metacarpo-phalangeal dislocation of the thumb, 
Fig. 963. 
Deformity resulting from dislocation of 
the thumb backward. 
* London Medical Gazette, 1837, vol. ii. 
j- Nelaton, E. de Pathol. Chir., t. ii. p. 420; Cooper's Surgical Dictionary, vol. i. p. 549. 84 
DISLOCATIONS. 
then carefully dissecting the thumb, I have no doubt that the last explanation 
is, in most cases, the correct one. 
When this luxation occurs, the anterior and lateral ligaments are neces- 
sarily lacerated. Immediately in front of the articulation, and attached to 
the first phalanx of the thumb, is a remarkably dense structure, formed by 
the tendinous insertion of the short flexor of the thumb, and the fibrous tissue 
derived from the ligaments and sesamoid bones. As the short flexor has a 
double origin, its two heads, as 
they converge to their insertion 
at the head of the proximal pha- 
lanx, leave an interval between. 
When, therefore, the thumb is 
luxated backward, it carries with 
it the short flexor, between the 
two portions of which is thrust 
the distal extremity of the meta- 
carpal bone, and it is there held, 
much afterthe manner of a button 
in a button-hole,-a simile which 
has been very appropriately em- 
ployed to describe this incarcera- 
tion. (Fig. 964.) 
It will be apparent, from the 
disposition of the parts, that ex- 
tension of the thumb made in the 
usual way would only serve to 
increase the difficulties of reduc- 
tion, by drawing this musculo-tendinous collar more firmly about the neck of 
the metacarpal bone. 
Reduction, in accordance with the pathological views just stated, can be 
accomplished in the following manner, and it must be done not by the exer- 
tion of great force, but by a rational manipulation. The surgeon, placing his 
fingers on the ulnar border of the hand and his thumb on the dorsal surface 
of the metacarpal bone, presses the latter strongly towards the palm of the 
hand. The object of this is to relax the two 
portions of the short flexor of the thumb 
which embrace the neck of the bone. The 
next step consists in grasping the thumb and 
raising it first to a perpendicular on the 
dorsum of the metacarpal bone, and then 
beyond a perpendicular, until its extremity 
points towards the wrist. The end of the 
phalanx by this movement becomes a wedge 
between the two tendons of the short flexor, 
and serves to conduct them over the head of 
the metacarpal bone. If now the finger of 
an assistant be placed behind the proximal 
phalanx to prevent its slipping back, and the 
thumb be brought down to the flexed pos- 
ture, the reduction will most probably follow. 
Professor Crosby's method.-This plan, really 
an old one, having been practiced by Sir C. 
Bell and by Gerdy, consists in first raising the 
phalangeal part of the thumb to a right angle 
with the metacarpal bone (Fig. 965) and then 
pressing the proximal phalanx from behind 
forward. 
The details of this procedure are as follows. Let the surgeon, seating him- 
self by the side of the patient, take his hand and place it upon his knee. 
Fig. 964. 
Metacarpal bone thrust between the two portions of the 
short flexor of the thumb. 
Fig. 965. 
Position of the phalanges in Crosby's 
method. DISLOCATION OF THE THUMB. 
85 
Then let him raise the dislocated phalanx to a little beyond a perpendicular 
with its metacarpal bone. Let him now, with his index fingers in front and 
his thumbs behind, press the base of the proximal phalanx forward until 
it glides over the distal extremity of the metacarpal bone. (Fig. 966.) 
So very obstinate has been the re- 
sistance of this dislocation that it has 
foiled the efforts of the most distin- 
guished surgeons to reduce it. In one 
instance the thumb was actually torn 
off in fruitless attempts to replace the 
phalanx. Accordingly, many sugges- 
tions have been made to overcome the 
supposed obstacles to replacement. 
Sir Charles Bell proposed the sub- 
cutaneous division of one of the lateral 
ligaments. Hamilton succeeded in re- 
storing a case which had successfully 
resisted other measures, as he believes, 
by dividing both lateral ligaments. 
Gibson, Porter, and others have been 
equally fortunate. This method, how- 
ever, has failed in the hands of Blan- 
din and others. 
It has also been proposed to open 
the integument behind the dislocated 
phalanx, and, by introducing a lever, 
to raise it over the distal extremity of 
the metacarpal bone. 
When it becomes necessary to re- 
sort to forcible extension, there are 
several mechanisms which can be ap- 
plied to the thumb for that object. 
Among the most efficient of these are 
the double noose, the lever-tractor of Dr. 
Levis (Fig. 967), and the forceps of 
Charriere. (Fig. 968.) The last-named has a strap of soft leather stretched 
between the prongs of each blade, which enables them to retain a firm and 
painless hold upon the thumb. 
Anaesthetics, while they may be given to save pain, possess no value as 
muscular relaxants in a case of 
dislocated thumb, the difficulty 
being a mechanical one. 
If, after exhausting the ordi- 
nary resources, the surgeon fails 
to reduce the phalanx, there re- 
mains yet another resort, namely, 
subcutaneous division of the ex- 
ternal tendon of the short flexor muscle of the thumb. In a ease which 
was brought into the University Hospital, after other means had failed, the 
reposition was ac- 
complished in this 
manner by Dr. 
Hunter. 
In old cases of 
thumb luxation, 
the articulation 
may be excised 
with advantage, and a movable joint obtained, as was done in one case by 
Bryant. 
Fig. 966. 
Manipulation in Crosby's method. 
Fig. 967. 
Levis's lever-tractor. 
Fig. 968. 
Charrtere's traction and lever forceps. 86 
DISLOCATIONS. 
After reposition of the bone, the thumb must be dressed with care so as 
to prevent the phalanx from becoming displaced. For this purpose a spica 
bandage should be applied to the thumb, completing the final turns of the 
roller by circulars of the metacarpus. 
Dislocation of the First Phalanx of the Thumb Forward. - This 
displacement, quite rare, may be produced by having the thumb violently 
bent backward, or by force applied directly upon the dorsal surface of the 
bone, as in striking a blow. In this luxation the proximal phalanx is placed 
in front of the metacarpal bone. (Fig. 969.) The thumb will be shortened. 
There will be a dorsal prominence,-the 
distal end of the metacarpal bone,-and 
a palmar prominence,-the posterior 
extremity of the proximal phalanx. 
The direction of the thumb may be very 
little changed from the natural one. 
Reduction is effected by first making 
traction on the phalangeal parts of the 
thumb, followed by strong flexion. In 
the event of failure to restore the dis- 
placed phalanx to its proper place by 
this plan, an opposite one may be adopted, viz., that of forcing the phalanx 
into a state of extreme extension, and afterwards employing traction. 
After reduction, a very light piece of binders' board should be moulded to 
the palmar surface of the thumb, and secured in place by a narrow roller. 
Dislocation of the Second Phalanx of the Thumb.-This, the most 
common of phalangeal luxations, may occur in two directions,-backward 
and forward. The relation of the two phalanges in either displacement is 
too obvious to require comment. 
In the backward luxation, which is the more common of the two, the 
phalanx can be restored by carrying the end of the thumb into a state of 
forced extension; and in the forward luxation, it can be restored by forced 
flexion. A plaster roller or a concave splint, applied to the palmar and lateral 
surfaces of the thumb, constitutes the best dressing. 
Dislocations of the Fingers. 
Dislocations of the fingers may take place at the metacarpo-phalangeal 
and at the phalangeal articulations. 
Metacarpo-Phalangeal Dislocation.-The index and the little finger, 
occupying the most exposed parts of the hand, are generally the subjects of 
this displacement. The direction of the luxation is most commonly back- 
ward, the proximal phalanx being driven upon the dorsal surface of the 
anterior extremity of the corresponding metacarpal bone. The disloca- 
tion backward is generally 
caused by a blow or fall re- 
ceived on the intermediary 
articulation. 
When the luxation is 
forward, it is probable that 
the finger has been forcibly 
bent backward. (Fig. 970.) 
The signs of the injury 
are so palpable as scarcely 
to admit of an error being made in recognizing it. And yet I have seen 
instances of the accident in which the lesion appears to have never been 
suspected. 
If the displacement is backward, there will be seen a hard and prominent 
projection, made by the posterior extremity of the proximal phalanx, resting 
on the dorsal surface of the distal end of the corresponding metacarpal bone. 
Fig. 969. 
Dislocation of the thumb forward. 
Fig. 970. 
Anterior metacarpophalangeal dislocation. DISLOCATIONS OF THE BONES OF THE PELVIS. 
87 
The finger will be shortened, and also fixed, either in the flexed or in the 
normal position. 
The reduction may be 
accomplished by grasping 
the finger, turning it back 
into the condition of for- 
cible extension, and then, 
while making traction, 
pressing the phalanx for- 
ward : usually the digit 
will then glide into place. 
(Fig. 971.) 
Another method, fre- 
quently practiced, is to make extension by the noose, by the lever-tractor of 
Levis, or by the Indian puzzle. 
The luxation forward is reduced by making counter-extension from the 
wrist, and extension from the luxated finger, followed by flexion. 
Dislocations of the Phalanges.-These luxations are most common at the 
intermediary articulations, and may be either complete or partial. 
The direction of the displacement which occurs between the first and second 
phalanges is usually backward, and occasionally forward, or lateral. The 
direction of the displacement between the second and third phalanges is either 
backward or lateral. 
These luxations are reduced by extension, counter-extension, and pressure, 
or by forcible backward extension or flexion, according as the displaced 
phalanx occupies a position behind or in front of the piece from which it has 
been separated. 
Compound Dislocations of the Thumb and Fingers. 
Compound dislocations of the thumb and fingers are not uncommon acci- 
dents. Of 34 luxations of the thumb admitted into the Pennsylvania Hos- 
pital, 19 were compound; and of 26 dislocations of the fingers, 17 were 
compound. When attended with much laceration of the soft parts or 
stretching of the tendons, tetanus is not an unusual sequence. 
If the vessels remain intact, the luxated phalanx should be replaced, the 
wound closed, and the articulation immobilized by placing the finger in a 
splint moulded to its surface. This should extend over the palmar aspect 
of the hand to the front of the arm, and be retained in place by a roller 
bandage. 
If the phalanx cannot be replaced with entire ease, or, when restored to 
position, has a tendency to reluxation, the extremity should be excised before 
reposition. 
DISLOCATIONS OF THE BONES OF THE PELVIS. 
The most superficial inspection of the ligamentous pelvis will make it evi- 
dent that nothing short of an extraordinary force will suffice to disjoin the 
articulating pieces which enter into its construction. Accordingly, we find 
that when a displacement does occur it is in almost all cases associated with 
a pelvic fracture, and with serious injury to the blood-vessels and to the viscera 
within. 
The dislocations of the pelvis which are possible are (1) displacement of 
the sacrum from the ilium,-sacro-iliac luxation,-and (2) displacement of the 
pubic bones at the symphysis. 
These dislocations are incomplete. 
They are produced by forces which are concentrated directly upon the 
luxated bone, or which subject the pelvis to severe pressure. Among these 
Fig. 971. 
Reduction of dislocation of the index finger at the metacarpo- 
phalangeal articulation. 88 
DISLOCATIONS. 
may be mentioned the falling of heavy masses of rock upon the pelvis, the 
passage of the wheel of a heavily-loaded wagon over the hips, or the com- 
pression of the hips between the buffers of railway-cars. A remarkable case 
of dislocation of the sacrum, without pelvic fracture, has been reported by 
J. Thoresby Jones, Assistant Surgeon to St. Bartholomew's Hospital, Chat- 
ham.* A man who had been knocked down by an engine, and who had 
measurably rallied from the shock attending the accident, died seven hours 
after the injury. The post-mortem revealed a partial luxation of the sacrum 
forward from both ilia; but no fracture existed. The external iliac vein on 
one side, and the ilio-lumbar artery on the other side, were wounded, and a 
considerable quantity of extravasated blood was found in the recto-vesical 
pouch. 
Dr. Thomas Harris, of Philadelphia, witnessed partial dislocations of the 
sacro-iliac and pubic symphyses in a woman, which were produced by a blow 
from the fist of her husband. 
Signs.-Dislocations of the pubic symphysis or of the sacrum must neces- 
sarily be difficult of detection. Preternatural mobility of the bones com- 
posing the former, and an unusual prominence of the posterior borders of 
the ilia, with a helpless state of the extremities, from injury to the sacral 
nerves, are signs which, if detected, would indicate those lesions. But in 
most cases the existence of these luxations will be more a matter of inference 
than of certainty. 
When the sacro-iliac junction of one side and the pubic symphysis are sepa- 
rated and displaced, we might expect an elevation of the injured side of the 
pelvis, with a shortening of the corresponding limb. Gibsonf witnessed a 
case of this luxation, and Professor Chaussierj; has reported one of the same 
nature. Professor Gross records a case of pathological separation of the 
pubes from softening of the interpubic fibro-cartilage in a woman during 
gestation, which rendered her unable to walk or to turn in bed without 
severe suffering. After parturition, the solidity of the articulation was 
slowly regained. A number of similar cases have been observed by Pare, 
Petit, Boyer, and others. 
Treatment.-The indications in pelvic luxations are the same as in pelvic 
fractures, viz., to attend to the state of the bladder by using the catheter 
when the patient is unable voluntarily to void the urine, to surround the 
pelvis with a broad bandage, and to prevent as far as possible the evil effects 
of inflammation. 
For the last-mentioned purpose, it is best to envelop the entire pelvis in 
hot flaxseed-meal poultices. They may be kept warm and moist by cover- 
ing them with a rubber-cloth, or with oiled silk. Pain must be relieved by 
opiates. 
Should the patient be fortunate enough to recover from the injury, a cer- 
tain degree of weakness of the walls of the pelvis, accompanied by dull 
pains, will probably be experienced, and will require the support of a firm 
bandage about the hips. The use of some of the plasters worn foi' the relief 
of muscular and other pains will also be productive of comfort. 
Dislocations of the Coccyx.-The coccyx may be luxated from the sacrum 
forward or backward, by external or by internal force. When the coccyx is 
displaced forward, it is usually due to a blow or a fall upon the cutaneous 
surface of the bone. When it is displaced backward, it is usually due to the 
pressure of the foetal head in preternatural labor. 
The injury is not only painful at the time of the accident, but it is likely to 
entail some degree of weakness on the lower extremities, and long-continued 
neuralgic suffering at the end of the bone. 
The dislocation can be satisfactorily diagnosed only by a digital explora- 
* British Medical Journal, July 6, 1878. 
f Gibson's Surgery, vol. i. 
j North American Medical and Surgical Journal, No. vii., July, 1827. DISLOCATIONS OF THE HIP OR THIGH. 
89 
tion made through the rectum. The reposition must be effected in the same 
way,-by making pressure and counter-pressure upon the bone with a finger 
of one hand introduced into the bowel, and with the fingers of the other 
hand acting on the outside of the bone. 
Rest in the recumbent position, with lotions of laudanum and water, and 
enforced constipation for eight or ten days, in order to prevent displacement 
from defecation, constitute the after-treatment. 
More or less deformity following the luxation may be anticipated. Should 
this consist of an anterior displacement, it may seriously interfere with the 
mechanism of labor. In such an event the excision of the bone would be the 
only resort. 
DISLOCATIONS OF THE BONES OF THE LOWER EXTREMITY. 
Dislocations of the bones of the lower extremity comprise, first, luxations 
of the hip,-coxo-femoral; secondly, luxations of the knee,-tibiofemoral; 
thirdly, luxations of the ankle,-tibio-tarsal; fourthly, luxations of the fibula, 
-peroneo-tibial; and, fifthly, luxations of the foot. 
Dislocations of the Hip or Thigh. 
Dislocations of the thigh, though stated to be second in order of frequency, 
according to the statistics of the Pennsylvania Hospital come third. Of 
912 cases of luxations admitted into this hospital, 89 were femoral. Of these 
89 cases, 78 were males and 11 females; 39 occurred between fifteen and 
twenty-five years of age; 26 between twenty-five and thirty; 12 between 
thirty-five and forty-five ; 6 between forty-five and fifty-five; 5 between 
fifty-five and sixty-five; and 1 between sixty-five and seventy-five. The in- 
frequency of this accident in the aged is to be attributed to changes in the 
structure of the bones, rendering them more fragile, and also to an increasing 
rigidity in the ligaments and muscles, in consequence of which the elasticity 
and flexibility of the body belonging to adolescent and adult life are meas- 
urably lost, thus predisposing the bones of the skeleton to fracture rather 
than to luxation. The youngest cases of dislocation of the femur of which 
I have any knowledge are one recorded by Mr. Powdrell,* occurring in a 
child six months old, in which the head of the bone occupied the foramen 
thyroideum, and one, of the same age, reported by Dr. Fanning, of Catskill, 
New York, to Professor Hamilton. Fanning's case was a girl, and the luxa- 
tion was on the dorsum ilii. Mr. Kirby, in the "Dublin Medical Press," and 
Dr. Buchanan, in the "London Medieo-Chirurgical Review,have each 
recorded a case of this luxation in a child three years old. In the first the 
head of the femur was on the dorsum ilii; in the second it was in the ischiatic 
notch. Few examples of femoral dislocation are met with after fifty years 
of age. Malgaigne notices five between sixty-five and eighty. Hamilton 
gives a case of Dr. Kline, of Portsmouth, Ohio, in which the patient, a woman, 
met with a luxation of the femur at seventy-three. And I find on the records 
of the Pennsylvania Hospital 5 such cases between seventy-five and eighty- 
five years of age. Professor Gibson met with a case in which both femurs 
were simultaneously dislocated, and Dr. Packard witnessed a similar one. 
One bone was dislocated on the dorsum ilii, and the other into the thyroid 
foramen. 
Varieties of Dislocation.-The head of the femur may occupy almost 
any situation on the innominate bone. But for all practical purposes coxo- 
femoral luxations can be studied under three forms. These are (1st) the ilio- 
ischiatic, of which there are two varieties, viz., a, upward and backward on 
the dorsum ilii (iliac luxation); b, upioard and backward into the ischiatic 
foramen (ischiatic luxation); (2d) forward and downward into the obturator 
* Lancet, May 16, 1868. 
j- Hamilton's Treatise on Fractures and Dislocations, 5th edition, p. 673. 90 
DISLOCATIONS. 
foramen {obturator luxation); and (3d) upward and forward on the pubis 
{pubic luxations). 
Deviations from these cardinal forms frequently exist. For example, the 
head of the femur may rest posteriorly on the shelving ridge which forms 
the outer wall of the acetabulum, or at any point between this and the semi- 
circular line on the dorsum ilii. Or it may be found at ,any point within a 
region extending from the top of the great sacro-ischiatic foramen down to 
the tuber ischii, below the acetabulum. On the upper and anterior aspects 
of the acetabulum the head of the bone may be found in the grooves external 
or internal to the ilio-pubic eminence; and, again, on any part of that sur- 
face which extends from the horizontal ramus of the pubes over the thyroid 
membrane, and to the tuber ischii below. 
Relative Frequency.-The most common dislocation is that on the dorsum 
ilii. Professor Hamilton has given the analysis of 104 hip dislocations, with 
the following result. There were 55 on the dorsum of the ilium ; 28 into 
the great ischiatic notch; 13 upon the thyroid foramen; and 8 upon the 
pubis. Bryant states that out of 54 cases, treated at Guy's Hospital and in 
his private practice, 27 were on the dorsum of the ilium, 12 into the thyroid 
foramen, 8 into the sciatic notch, and 7 on the pubis. 
Difficulties of Reduction.-There has been considerable diversity of 
opinion in regard to the obstacles which resist reduction of the femur. It 
was the opinion of Sir Astley Cooper and others that the chief difficulty 
consisted in muscular resistance, though these writers were not agreed as to 
what muscles were most concerned in opposing reposition. Others believed 
that the obstruction lay in the insufficient size of the rent made in the cap- 
sular ligament; while a third set of authorities attributed the difficulty of 
reduction partly to muscular and partly to ligamentous resistance. 
For a better understanding of this sub- 
ject, I will state that when the head of 
the femur is luxated upward and back- 
ward, the muscles on the inner aspect 
of the articulation are placed upon the 
stretch, and not unfrequently are par- 
tially torn. These muscles are the psoas 
magnus, the iliacus internus, the obtu- 
rator externus, and the three adductors. 
Those muscles on the posterior aspect 
which are rendered tense, and portions 
of which may also be torn, are the quad- 
ratus femoris, the obturator internus, the 
gemelli, and, in a less degree, the pyri- 
formis. The three glutei muscles are, 
from the position of the bone, necessarily 
relaxed. In the opinion of Reid, the 
resistance to the reposition lay first in 
the muscles situated posterior to the 
joint, and finally in those anterior to it. 
In 1858, Dr. Norcum, of South Caro- 
lina, made some dissections of the hip- 
joint, to which he called my attention, 
and which were conclusive, to our minds, 
that under a proper manipulation there 
could be no serious muscular opposition 
experienced in replacing a luxated thigh- 
bone. Observations still more decisive* 
have been made upon the cadaver by 
Fenner, Gunn, Moore of Rochester, and 
Bigelow, in this country, which locate the entire resistance in the untorn 
Fig. 972. 
Ilio-femoral, or the Y ligament of Bigelow. 
* American Journal of the Medical Sciences, vol. xxv. p. 280. DISLOCATIONS OF THE HIP OR THIOH. 
91 
portion of the capsular ligament. In Von Pitha and Billroth's work on Sur- 
gery, similar views are expressed in regard to the mechanism of the ilio- 
femoral part of this ligament, proving that the subject has not escaped the 
keen observation of our German brethren. 
To Professor Bigelow, of Boston, however, the profession is indebted for 
an exceedingly thorough and, in a great measure, original exposition of the 
mechanism of femoral dislocations. This distinguished surgeon designated 
the ilio-femoral thickening of the capsular ligament the Y ligament. This 
dense mass of fibrous tissue, which serves to reinforce anteriorly the cap- 
sular ligament of the hip, consists below of two branches, which have a 
common origin from the anterior inferior spinous process of the ilium, 
the external limb being inserted into the outer part of the anterior inter- 
trochanteric line, and the inner limb into the internal portion of the same 
ridge. (Fig. 972.) 
The two branches or layers are connected together by a thinner layer of 
the capsular ligament. An idea of the strength of the Y ligament may be 
gathered from the fact that, under the severe tests to which it has been sub- 
jected, it is competent, according to Professor Bigelow, to sustain from two 
hundred and fifty to seven hundred and fifty pounds. 
On the integrity or on the rupture of the Y ligament Bigelow founds his 
classification of coxo-femoral dislocations, namely, into regular and irregular 
luxations. The first, or regular luxations, are those in which both branches 
of the Y ligament remain untorn. These are practically the three cardinal 
forms of the luxation already named. In the second, or irregular luxation of 
Bigelow's classification, both branches of the Y ligament are ruptured, and 
the head of the bone may occupy almost any position intermediate to the 
regular ones. 
Dislocation Upward and Backward,-Iliac.-Tn this luxation the head of 
the femur, after rupturing the posterior part of the capsular ligament and 
the ligamentum teres, escapes from the acetabulum and is lodged on the 
dorsum of the ilium, either above or below its inferior semicircular line. (Fig. 
973.) < 
Causes.-The excitement attending a dislocation and the instantaneous 
manner of its production render it very difficult to define the exact state or 
posture of a limb at the time of the accident. But we are warranted in 
assuming that, in a luxation of the femur upon the dorsum ilii, the deter- 
mining force must act on the limb while the latter is in a state of adduction, 
or by causing its violent internal rotation. In either way the pressure of the 
head of the bone will be brought to bear against the outer aspect of the cap- 
sular ligament. Accordingly, it is found that these luxations have been pro- 
duced by falls upon the knee or the foot at a time when, it is believed, the 
injured limb was directed across the sound one; or by a crushing weight 
descending on the back when the pelvis was flexed on the thighs, as when 
one bends forward; or, finally, by the foot or thigh being caught and fixed 
while the hips were forcibly twisted. 
Symptoms.-When practicable, the patient should always be in the standing 
position when the examination is made. 
The thigh is somewhat flexed and adducted. The knee of the injured limb 
is a little in front of and a little above the knee of the sound limb. The 
hip, in consequence of the new position of the trochanter major, is unduly 
prominent. The foot is strongly inverted (from the resistance of the ex- 
ternal branch of the ilio-femoral ligament), the ball of the great toe resting 
against the inner side of the opposite instep. (Fig. 974.) 
When the patient is not too obese or muscular, the head of the femur 
can be felt in its abnormal position, moving under the fingers when the thigh 
is rotated. The limb is shortened, the degree of shortening varying from 
one inch to two and a half inches, depending altogether upon the position 
occupied by the head of the bone on the dorsum ilii. Flexion and extension 92 
DISLOCATIONS. 
of the injured limb can be made without much resistance; but adduction 
and abduction, especially the latter, are almost impossible. 
Diagnosis.-The only affections of the hip which are likely to be con- 
Fig. 974. 
Fig. 973. 
Dislocation on the dorsum ilii. 
Dislocation on the dorsum of the ilium. 
founded with this luxation are fracture of the neck of the femur, fracture 
of the acetabulum, and coxalgia. 
From fracture of the neck of the femur the diagnosis may be established 
as follows: 
LUXATION. 
Hip very prominent. 
Knee adducted and limb flexed. 
Foot inverted. 
Limb cannot be restored to its proper length 
by ordinary force; and when restored, it remains 
so. 
No crepitus. 
Limb quite immovable. 
FRACTURE OF THE NECK. 
Hip not prominent. 
Knee not adducted, and limb not flexed. 
Foot everted. 
Limb readily restored to its proper length by 
extension, but immediately shortens upon the 
withdrawal of the extending force. 
Crepitus. 
Limb movable. 
In fracture of the neck of the femur with impaction, especially when the 
foot is inverted, there may be some further difficulty in reaching a satisfac- 
tory diagnosis. But if it be remembered that in the latter injury (fracture) 
adduction, abduction, and rotation can still be made without restriction 
other than that resulting from the pain consequent on these movements, and 
if, in addition, the position of the great trochanter, on a level with the acetab- DISLOCATIONS OF THE HIP OR THIGH. 
93 
ulum, be contrasted with the position which this process takes in luxation, 
behind and above the articulating cavity, there should be no serious difficulty 
in comprehending the nature of the lesion. 
Greater embarrassment will be experienced in distinguishing the luxation 
under consideration from fracture of the posterior lip of the acetabulum; 
for in the latter accident the head of the bone is prone to become displaced 
backward and upward. Hero the surgeon will have to reach a diagnosis 
founded on the marked mobility, the existence of crepitus, and the constant 
tendency of the bone to escape from its articulating cavity after being 
reduced,-signs which belong to fractures of the posterior border of the 
acetabulum. 
It might be supposed that no one would be capable of committing so egre- 
gious a blunder as to mistake a case of coxalgia for one of dislocation of the 
femur on the dorsum ilii. Yet Norris mentions an instance of the kind, and 
I have seen the same error committed in two cases. The age of the child, the 
flattening of the buttock, the absence of any sufficient injury, the apparent 
elongation of the limb, the history of a limp in walking, with the eversion 
of the foot, would be quite sufficient to render such a mistake inexcusable. 
Dislocation Upward and Backward,-Ischiatic.-This is sometimes de- 
scribed as the ilio-sciatic luxation. It answers to the dislocation into the 
sacro-sciatic notch of Sir Astley Cooper (Fig. 975), and according to Bigelow, 
Fig. 975. 
Fig. 976. 
Ischiatic dislocation, or dorsal below the tendon of the obturator 
internus muscle. 
Dislocation into the great sciatic notch. 
who makes it one of the varieties of a dorsal luxation, it is dorsal below the 
tendon of the obturator internus muscle. The head of the bone may occupy 
the upper portion of the notch (Fig. 976), or it may be placed across the 
same, covering to a considerable degree this opening down to the lesser 
sacro-ischiatic ligament. 
This dislocation requires for its production a position of the limb at the 
time of the accident a little different from that which predisposes to the iliac 
variety; that is to say, when the determining force is applied to the knee, 
the foot, or the pelvis, the femur must probably approximate a right angle 
with the body. 94 
DISLOCATIONS. 
The muscular lesions which accompany this luxation are by no means uni- 
form. Sometimes the gluteal muscles escape any serious laceration; at 
other times they are extensively torn. The gemelli and obturator externus 
muscles may also participate in the laceration. 
Symptoms.-The limb is slightly flexed, inverted, and adducted. The knee 
is turned towards its fellow, touching the thigh at the inner margin of the 
patella. The limb is rarely shortened more than half an inch, and the short- 
ening may not reach that amount. The extremity of the great toe of the 
injured limb touches the meta- 
carpo-phalangeal articulation 
of the corresponding toe of the 
sound limb. The hip is less 
prominent, and the trochanter 
farther from the anterior su- 
perior spinous process of the 
ilium; the numbness and pain 
from pressure on the ischial 
nerve are greater; the bone is 
less movable, and its head is 
lower down, than in the iliac 
variety of the luxation. (Fig. . 
977.) When the patient is 
placed in the recumbent posi- 
tion on the back and upon a 
firm mattress, or on the floor, 
and an attempt is made to 
straighten the limb, it is ac- 
companied by a characteristic 
arching of the lumbar part of 
the back, which disappears 
when the limb is flexed. 
These important symptoms, 
developed by the alternate ten- 
sion and relaxation of the psoas 
magnus and iliacus internus 
muscles, first noticed by Mr. 
Syme, are both characteristic 
and differential, as they do not 
exist in the order mentioned in 
any other injury or disease of 
the hip-joint. 
In addition to these means 
of diagnosis may be mentioned 
another, given by Dr. Squires, 
of Elmira, for diagnosing more 
particularly old ischiatic lux- 
ations, but which Hamilton has 
shown to be not less applicable to more recent ones, viz., a digital examination 
made through the rectum or the vagina. 
Reduction of Iliac and Ischiatic Dislocations.-There are two methods of 
reducing femoral luxations,-by manipulation and by extension and counter- 
extension. 
Reduction by Manipulation.-The patient, being placed on his back upon 
a firm mattress, or upon a comfortable or quilt doubled on itself and laid on 
the floor, should be brought under the influence of an anaesthetic. The sur- 
geon, kneeling by his side, grasps the ankle of the injured limb with one 
hand, and the front and sides of the knee with the other. The leg is next 
flexed on the thigh, and the thigh upon the pelvis. After this, the limb is 
Fig. 977. 
Ischiatic dislocation. REDUCTION OF ILIAC AND ISCHIATIC DISLOCATIONS. 
95 
adducted, carried to the sound side, rotated slightly outward, and finally, 
by external circumduction, is swept across the abdomen and brought down 
to the straight position alongside of its fellow. The head of the bone usually 
glides into the cotyloid cavity with an audible sound at the termination of 
the circumduction. (Fig. 978.) 
Fig 978. 
Iteduction of iliac and ischiatic dislocation by flexion, adduction, external rotation, and circumduction. 
The mechanism of the reduction is as follows. By flexing the thigh on the 
pelvis, in the iliac dislocation, the ilio-femoral ligament is relaxed, and the 
head of the bone is free to move downward towards the outer and lower 
margin of the acetabulum. In the ischiatic luxation, flexing the thigh on the 
pelvis serves to disengage the head of the femur from the tendon of the ob- 
turator internus muscle. The abduc- 
tion compels the bone to hug the side of 
the articulating cavity, and the external 
rotation and circumduction, by wind- 
ing the outer branch of the ilio-femoral 
ligament round the neck of the bone, 
raises the head of the femur over the 
acetabulum, on the principle of the 
windlass or sliding fulcrum. (Fig. 979.) 
It is possible during the manipulation, 
especially while making abduction, by 
using too much force, to lacerate the 
posterior portion of the capsular lig- 
ament to such an extent as to allow the 
head of the bone too much liberty, in 
consequence of which it may descend 
below or even swing round in front of 
the acetabulum. A ease of iliac luxation 
was sent to the Pennsylvania Hospital, 
in which a number of fruitless efforts 
had been made to replace the head of the bone before the admission of the 
patient, but wThich had doubtless been thwarted by the laceration just men- 
Fig. 979. 
The operation of the ilio-femoral ligament in 
winding the head of the femur towards the acetab- 
ulum, on the principle of the windlass. 96 
DISLOCA TIONS. 
tioned. On the first attempt to reduce the bone by manipulation, I was 
satisfied, from the behavior of the limb, that this was the case. The chord 
of the arc was too long. By placing a sheet around the thigh at a right 
angle with the limb, and intrusting it to an assistant, who was directed to 
make outward traction during the external rotation and circumduction of 
the thigh, the reduction was effected without difficulty. 
Not unfrequently the reduction can be made by raising the limb on the 
hand placed in the popliteal region as a fulcrum during the movements 
of external rotation and circumduction. 
An oscillating movement of the thigh is sometimes practiced with success 
at the same stage of the process. 
.Reduction by Extension and Counter-Extension.-Morgan introduced 
into Guy's Hospital a plan for applying extension and counter-extension in 
coxo-femoral luxations, very similar in its operation to that practiced by 
Cooper and others in dislocations of the humerus. A foot was placed between 
the thighs and against the perineum, to exert counter-extension, while exten- 
sion and rotation were made by assistants from a band attached to the thigh 
above the knee. The limb, during the application of these forces, should be 
carried towards its fellow, making the foot a fulcrum, in order to press the 
bone off from the pelvis. Cock* succeeded in replacing three dislocations of 
the thigh in the same hospital, by the same method, one being a luxation on 
the pubic bone. 
When it becomes necessary to employ greater force, extension can be made 
by bands attached above or below the knee. The former position is to be 
preferred, as by leaving the leg free it can be used as a lever to aid in the 
reduction. 
This method is the one generally adopted by English and American sur- 
geons. Gerdy increased his points of extension by including both the thigh 
and the leg in his extending bands. 
Counter-extension must be applied to the perineum of either the sound or 
the injured limb. Gibson preferred the former; but practically it is a matter 
of no importance on which side the band is placed, as the resistance to be 
encountered is not so much muscular as it is ligamentous and osseous. Con- 
sequently, the stimulation of the adductors, by the pressure of the counter- 
extending band on the perineum of the injured side, is a matter of little 
importance. A thick compress should be interposed between the perineum 
and the counter-extending band. 
As the pelvis, during extension and counter-extension, is prone to be twisted 
round, it will become necessary to counteract this tendency by passing a folded 
sheet transversely about the hips, at a right angle with the counter-extending 
band, and fastening it to the side of the bed, or intrusting it to an assistant, 
who, by drawing on the same, maintains the patient in a proper line. 
The thigh, during extension and counter-extension, should be somewhat 
flexed on the abdomen, and the leg bent upon the thigh, the limb being at 
the same time carried towards its fellow,-a position favorable to the dis- 
lodgment of the head of the femur from behind the acetabulum. 
Extension to any degree required may be obtained by the use of pulleys, 
first introduced into the surgery of dislocations by Ambrose Pare. The 
patient should be laid flat upon a low bed having a firm mattress, or upon 
a strong table, previously covered with a heavy quilt. The counter-extending 
band must next be passed through the perineum, and its end secured to a 
foot of the bedstead. A sheet, after being folded into a band, and wet with 
water, to prevent slipping, should be formed into a reversed noose, slipped over 
the leg, and tightened around the lower part of the thigh, a short distance 
above the knee. The ends of the fillet being now tied together form a loop. 
Into this loop one hook of the pulley is passed, while the other is secured to 
a staple in a post or wall, at an elevation which will admit of the thigh being 
flexed while extension is made. (Fig. 980.) 
® Guy's Hospital Reports, vol. i. p. 79; Chelius's Surgery, vol. ii. p. 241. REDUCTION OF ILIAC AND ISCHIATIC DISLOCATIONS. 
97 
Another sheet must be carried round the pelvis transversely, and given to an 
assistant, with a view to prevent the obliquity and the descent of the pelvis 
which would otherwise be caused by the extension. 
The arrangements for the reduction are now complete. The surgeon, 
Fig. 980. 
Reduction of an iliac dislocation by the pulleys. 
committing the cord of the pulleys to an assistant, directs the extension to 
be made in a very gradual manner, until the muscles become wearied, or, 
as not unfrequently occurs, a portion of the capsular ligament gives way. 
Then, by rotating the limb outward and carrying it towards the sound side, 
at the same time suddenly letting go the extension, the head of the bone 
will probably resume its functional position in the cotyloid cavity with an 
appreciable slip. 
When the dislocation is ischiatic, the only modification necessary is to apply 
the extension with the thigh somewhat more flexed than in the iliac variety. 
(Fig. 981.) 
Fig. 981 
Reduction of an ischiatic dislocation by the pulleys. 
In the absence of the pulleys, the Spanish windlass of Gilbert (Fig. 905) 
may be advantageously substituted. 
VOL. II.-7 98 
DISLOCATIONS. 
Whether manipulation or extension and counter-extension be adopted for 
the reduction, there is a probability that the head of the bone will change 
its place without entering the acetabulum. The luxation may readily be 
converted into an ischiatic or even into an obturator luxation, so that the 
closest scrutiny of the joint is necessary to ascertain that no mistake has 
been made. 
If, upon comparing the two limbs, they are found to be of the same length, 
the foot of the injured limb being neither inverted nor everted ; if the rotation, 
abduction, and adduction of the latter be free; and if the measurements on 
both sides between the trochanter major and the anterior superior spinous 
process of the ilium, and between the trochanter major and the tuberosity 
of the ischium, are found to correspond, there can remain no doubt as to the 
certainty of the reduction. 
This point determined, the knees of the two limbs should be bandaged to- 
gether, a towel being interposed to protect the contiguous surfaces. After 
seven or eight days, gentle movements of the thigh should be made, with 
a view to prevent stiffness of the joint. In two weeks the patient may be 
allowed to move about on crutches. 
Dislocation of the Head of the Femur Downward and Forward.-This lux- 
ation is produced by a sufficient force acting upon tbe limb while it is in a 
state of abduction, in which position the bead of the femur lacerates the 
inner and posterior aspects of the capsular ligament, and, passing through it, 
is lodged over the thyroid foramen upon the obturator externus muscle. 
(Figs. 982, 983.) 
Fig. 982. 
Fig. 983. 
Position of the head of tlie femur in the luxa- 
tion downward and forward, and its relation to 
the ilio-femoral ligament. 
Downward and forward dislocation 
of the head of the femur. 
The accident may occur without rupture of the ligamentum teres, a fact 
which I ascertained by the dissection of a luxation of this nature. A female 
patient was once under my care in the Philadelphia Hospital who could 
produce this dislocation at pleasure. DISLOCATION OF THE HEAD OF THE FEMUR. 
99 
Symptoms.-The limb is lengthened, rarely more than one inch and a half; 
it is abducted; it is also in advance of its fellow. The heel is somewhat 
raised when the body is erect; the toes are generally directed forward, and 
occasionally are everted. The hip is flattened, and the body inclined forward 
on the pelvis and towards the injured side. The head of the bone may also 
be felt below the horizontal ramus of the pubes. 
The anatomical explanation of the phenomena present in thyroid disloca- 
tions is this. The increased length of the limb follows from the position of 
the head of the femur, the thyroid foramen being lower than the acetabulum. 
The abduction is due partly to the tension of the inner branch of the ilio- 
femoral ligament when this is not torn, but chiefly to that of the glutei, 
the psoas magnus, iliacus internus, and external rotator muscles of the hip. 
The flattened state of the hip results from the elongation of the gluteal 
muscles; and the forward inclination of the body is an instinctive movement 
made to relax the psoas magnus and iliacus internus muscles. 
The elongation and rigidity of the limb, together with the absence of 
crepitus, are sufficient to distinguish this dislocation from fracture at the 
neck of the femur. 
Reduction by Manipulation.-Flexing the leg and the thigh, the limb is 
carried up at a right angle with the pelvis, in a position of abduction, by 
which the psoas magnus and internal iliac muscles and the ilio-femoral lig- 
ament are relaxed. The limb is next adducted and rotated inward, by 
which means the internal branch of the ligament is wound round the neck 
of the bone, raising the latter towards the acetabulum. Finally, the limb 
is carried across the abdomen 
towards the sound side, and 
brought down in a position of 
adduction to the side of its fel- 
low. (Fig. 984.) 
Reduction is more likely 
to occur if, at the time the 
circumduction across the ab- 
domen is being executed, one 
hand is placed in front of the 
thigh and the other in front 
of the knee, the two strongly 
antagonizing each other, so as 
to force the femur away from 
the pelvis, at the same time that 
it is elevated or lifted upward. 
This precaution will often pre- 
vent the head of the bone from 
swinging round below the cot- 
yloid cavity and thus convert- 
ing a thyroid into an ischiatic 
or even into an iliac luxation. 
The same object is attained 
by passing a fillet beneath the 
upper part of the thigh and 
raising the latter at the mo- 
ment the limb begins to de- 
scend. When the head of the bone has glided into the posterior position, I 
have succeeded in effecting reduction by adopting manipulation for the iliac 
and ischiatic displacements. 
Reduction by the Pulleys.-Sir Astley Cooper's plan of using the pulleys 
in this dislocation was, after placing the patient flat on the back, to pass a 
strong band upward and outward through the perineum of the dislocated 
limb, and to fasten the band to a pulley. A second band was carried around 
the pelvis and given to an assistant stationed on the sound side of the patient. 
Fig. 984. 
Rednction of an obturator dislocation by manipulation. 100 
DISLOCATIONS. 
The pulleys having been tightened, so as to draw the upper extremity of the 
femur outward, the surgeon, passing his hand beneath the sound limb, 
Fig. 985. 
Reduction of an obturator dislocation by the pulleys. 
grasped the ankle of the injured one, and, as soon as the bone was felt to 
move, drew the latter strongly inward. (Fig- 985.) 
Dislocation of the Head of the Femur Upward and Forward.-The dislo- 
cation of the femur upward and forward usually occurs from falls upon the 
foot or upon the knee when the thigh is thrown far back behind the per- 
pendicular, or it may be produced by a violent twist of the limb. 
In this luxation the head of the bone, after lacerating the anterior and 
inner aspect of the capsule and rupturing the round ligament, is forced upon 
the pubes, and takes a position generally internal to the pubic eminence, in 
front of the horizontal ramus of the pubes (Fig. 986), or, occasionally, ex- 
ternal to this ridge, in the muscular groove below the anterior inferior spinous 
process of the ilium. 
The femoral artery and vein are always on the inner side of the bone. 
This luxation is extremely rare. I have seen but a single instance of the 
kind. 
Symptoms.-The limb is shortened and abducted, the foot is strongly 
everted, and the thigh is moderately flexed. The head of the bone can be 
felt in front of the pubes; the trochanter recedes from the surface so as 
scarcely to be recognized; and the extremity assumes a rigid and fixed 
position. (Fig. 987.) 
The abduction and eversion of the limb are caused by the tension of the 
anterior branch of the ilio-femoral ligament and the external rotator muscles. 
The differential diagnosis between a fracture of the neck of the femur and 
this luxation will be established by the following considerations: in fracture 
there are crepitus, undue mobility, no flexion of the thigh, no abduction, and DISLOCATION OF THE HEAD OF THE FEMUR. 
101 
the trochanter major is easily distinguished. In pubic dislocation there is 
Fig. 986. 
Fig. 987. 
Position of the head of the femur in a pubic 
dislocation. 
an entire absence of crepitus, the limb 
is immovable, and the thigh is flexed 
and abducted; to which signs may 
be added the spherical form of the 
tumor in front of the pubes, so un- 
like the end of a broken bone. 
Reduction by Manipulation.- 
The reduction may be accomplished 
by almost the same movements as 
those employed in thyroid disloca- 
tions, only modified in the degree of 
flexion and abduction. The flexion 
should be to the fullest extent, bring- 
ing the thigh into contact with the 
abdomen. This is done to relax the 
ilio-femoral ligament, and to dislodge 
the head of the bone from the pubes, at the same time forcing it in front 
Position of the limb in dislocation of the pubis. 
Fig. 988. 
of the pubes, or even into the thyroid foramen. Then, after making internal 
Reduction of the upward or pubic dislocation by extension and counter-extension. 102 
DISLOCATIONS. 
rotation and adduction, the limb should be brought down inclined to the 
sound side. In a case of pubic dislocation which had resisted a number of 
well-applied efforts at reduction, 1 succeeded in effecting the reposition by 
these movements. 
Reduction by Extension and Counter-Extension.-The manner of ap- 
plying these forces, as formerly practiced, consisted in attaching the end of 
the counter-extending perineal band to a hook above and in front of the body 
of the patient, and in making the extension by the pulleys in a downward 
direction. (Fig. 988.) As soon as the muscles were wearied and the bone 
began to yield, a fillet was placed under the upper part of the thigh, and the 
femur wTas raised sufficiently to clear the edge of the acetabulum. 
Anomalous Dislocations. 
Dislocations are occasionally encountered which cannot be properly classed 
under any of the three general divisions which have been described. To 
these the name unusual, or, more properly, anomalous luxations, has been 
given. Professor Bigelow, in his classification of these injuries, considers 
none entitled to this distinction except those in which both branches of the 
ilio-femoral ligament are ruptured. In these cases the head of the bone, 
being released from all restraint, is left to the uncontrolled force of muscular 
action. This is no doubt true in many instances, but cannot be so in all. 
Otherwise we should have a greater uniformity in the symptoms following 
these different displacements. 
These anomalous dislocations may be arranged under three general divisions, 
namely, upward (supra-cotyloid, or above the level of the cotyloid cavity), 
downward (infra-cotyloid, or below the level of this cavity), and forward, 
or subpubic. 
The following table, prepared chiefly from materials gathered from Cooper, 
Hamilton, and others, will exhibit, in a concise form, most of the recorded 
cases of anomalous luxation : 
Table of Anomalous Dislocations of the Femur. 
UPWARD, OR SUPRA-COTYLOID DISLOCATIONS. 
No. 
Name of Sur- 
geon or Hos- 
pital. 
1 
Position of the 
Head of the Bone. 
Characteristic 
Phenomena. 
Treatment. 
Result. 
Reference. 
1 
Guy's Hus- 
External to the 
Toes everted and 
None. 
Died of other 
Lancet, 1840-41, 
pital. 
anterior inferior 
spinous process. 
turned quite out- 
ward and back- 
ward. Abduc- 
tion. 
injuries. 
vol. ii. p. 281. 
2 
M. Wormaid 
(old luxation 
unreduced). 
Between the coty- 
loid cavity and 
the anterior in- 
ferior spinous 
process of the 
ilium. 
Slight shortening 
and abduction of 
the limb. 
None. 
Died . of 
pneumo- 
nia 17 
years after 
injury. 
London Med. Gaz. 
for 1836-37, p. 
658. 
3 
Mr. Travers 
(old luxa- 
tion). 
Neck of the bone 
between the two 
spinous pro- 
cesses. 
Complete eversion; 
flat buttock; tro- 
chanter major 
high and ante- 
rior. 
None. 
Med.-Chir. Trans., 
vol. xx. p. 113. 
4 
Morgan. 
Neck of the bone 
between the two 
spinous pro- 
cesses. 
Complete eversion ; 
flat buttock; tro- 
chanter major 
high and ante- 
rior. 
None. 
Philadelphia Med. 
Examiner, No. 
51, Miitter's pa- 
per. 
5 
Cummins. 
Below the anterior 
superior spinous 
process. 
Three inches short- 
ening; toes 
everted. 
Extension by pul- 
leys and eleva- 
tion of the thigh. 
Cured. 
Guy's Hosp. Re- 
ports, vol. viii. 
6 
Lente. 
Secondary luxation 
below the ante- 
rior superior spi- 
nous process. 
Shortening 2 inch- 
es, and limb ro- 
tated outward 
very much. 
Reduction by 
pulleys and rota- 
tion in different 
directions. 
Cured. 
New York Jour, of 
Med., Nov. 1850, 
p. 314, 
7 
Agnew. 
Inside of the ante- 
rior inferior spi- 
nous process. 
Shortening 2 inch- 
es; eversion and 
abduction of 
limb. 
Manipulation. 
Cured. ANOMALOUS DISLOCATIONS. 
103 
DOWNWARD, OR INFRA-COTYLOID LUXATIONS. 
No. 
Name of Sur- 
geon or Hos- 
pital. 
Position of the 
Head of the Bone. 
Characteristic 
Phenomena. 
Treatment. 
Result. 
Reference. 
1 
Keate. 
On the tuberosity 
Lengthened over 3 
Reduced, but mode 
Cured. 
London Med. Gaz., 
of the ischium; 
inches; much 
not stated. 
vol. x., 1832, p. 
believed to be 
eversion; thigh 
19. 
2 
Mr. Gurney, 2 
cases. 
secondary. 
One a little for- 
ward and the 
strongly flexed. 
Elongation and 
eversion of the 
Reduced, but mode 
not stated. 
Lancet, vol. i. p. 
412. 
other a little 
limb. 
backward. 
3 
M. Bouisson. 
A little backward. 
Lengthened 2 inch- 
By fracture of the 
Cured. 
Gaz. Med., 1853, p. 
es; flexed, ab- 
thigh in the 
064. 
ducted, and ro- 
flexed position. 
tated outward. 
4 
Kirkbride. 
Head of the bone 
between tuberos- 
Thigh and leg 
flexed; knee be- 
By pulley exten- 
sion and lifting 
American Jour. 
Med. Sciences, 
ity and spine of 
ischium. 
low its fellow; 
toes inward, and 
the thigh. 
vol. xvi. p. 13. 
limb shortened 1 
inch 
5 
Roux. 
Upon inner side of 
ischium. 
Lengthened nearly 
2 inches, flexed, 
Manipulation by 
flexion, abduc- 
Cured. 
Rev. Med. Chir., 
tom. v. p. 364. 
and abducted. 
tion, and out- 
ward rotation 
after direct ex- 
tension had 
failed. 
6 
J. 0. Warren. 
In the lesser ischi- 
atic notch. 
Limb lengthened, 
adducted. 
No attempt to re- 
duce the luxa- 
New York Med. 
and Phys. Jour., 
tion, being of 3 
months' stand- 
vol. v. p. 397, 
1826. 
7,8 
Travers (2 
Ischial tuberosity 
Inversion. 
mg. 
Med.-Chir. Trans., 
cases of dis- 
and resting on 
vol. xx. p. 115. 
section; old 
spine of ischium. 
9 
cases). 
Quain (dissec- 
Head of femur had 
Med.-Chir. Trans., 
tion). 
passed beneath 
the sciatic nerve. 
vol. xxxi., 1848, 
p. 337. 
London Med. Gaz., 
10 
Mr. Wormaid 
Ischial tuberosity. 
Shortened and in- 
(dissection). 
verted; femur 
crossed the sym- 
vol. xix., 1837, p. 
557. 
physis pubis, and 
fixed. 
11 
Mr. Luke. 
On tuberosity of is- 
chium. 
Lengthened 1 
inch; toes 
neither everted 
Manipulation. 
Death from 
other inju- 
ries. 
Med. News and Li- 
brary, vol. xv. p. 
34, from Med. 
nor inverted, but 
Times and Gaz., 
adducted. 
Jan. 2,1838. 
12 
Blackman, of 
Cincinnati. 
Directly down- 
ward. 
Manipulation. 
Hamilton on Frac- 
tures and Dislo- 
cations, 5th edit., 
p. 725. 
FORWARD, SUBPUBIC, OR PERINEAL DISLOCATIONS. 
No. 
Name of Sur- 
geon or Hos- 
pital. 
Position of 
Head of the T 
the 
one. 
Characteristic 
Phenomena. 
Treatment. 
Result. 
Reference. 
1 
Pope. 
Behind the scro- 
tum, underneath 
the raphe. 
Thigh adducted to 
a right angle 
with the body; 
retention of 
urine. 
Pulley extension. 
Cured. 
New York Jour, of 
Med., March, 
1852, p. 198. 
2 
Parker. 
Behind the 
turn. 
scro- 
Thigh adducted to 
a right angle 
with the body. 
Extension down- 
ward and out- 
ward ; brought 
the head of the 
bone into the 
thyroid foramen; 
thence to theace- 
tabulum by car- 
rying the lux- 
ated limb across 
the sound one. 
Cured. 
N. Y. Med. Gaz., 
1841. 104 
DISLOCATIONS. 
No. 
Name of Sur- 
geon or Hos- 
pital. 
Position 
Head o 
of the 
the Bone. 
Characteristic 
Phenomena. 
Treatment. 
Result. 
Reference. 
3 
M. d'Amblard. 
Behind 
turn. 
the scro- 
Limb directed out- 
ward ; retention 
of urine. 
Extension down- 
ward and out- 
ward ; brought 
the head of the 
bone into the 
thyroid foramen; 
thence to the ace- 
tabulum by car- 
rying the lux- 
ated limb across 
the sound one. 
Cured. 
Malgaigne, t. ii. p. 
870. 
4 
Hodder. 
Under arch of pu- 
bes. 
Thigh at almost a 
right angle with 
body. 
Extension down- 
ward and out- 
ward ; brought 
the head of the 
bone into the 
thyroid foramen; 
thence to the ace- 
tabulum by car- 
rying the lux- 
ated limb across 
the sound one. 
Cured. 
British American 
Journa , 1861. 
FORWARD, SUBPUBIC, OR PERINEAL DISLOCATIONS-{Continued). 
In the supra-cotyloid dislocations, the predominant characteristics were 
strong eversion, variable shortening, and abduction of the limb. When the 
shortening has been observed, it must, doubtless, be referred to an induced 
obliquity of the pelvis. 
In the infra-cotyloid dislocations, eversion, abduction, and elongation con- 
stitute the leading signs. But when the head of the bone is a little posterior 
or near to the spine of the ischium, inversion and adduction are sometimes 
noticed. 
In the subpubic or perineal luxations, the distinguishing feature is an almost 
rectangular position of the limb with the body. 
Partial or Incomplete Luxations of the Hip. 
We are not at present in possession of any facts which can be considered 
as conclusive on the subject of incomplete luxations of the hip-joint. Mal- 
gaigne clearly recognizes such displacements; he did not deem a laceration 
of the capsule necessary for the production of partial luxations, only insisting 
on the necessity of the head of the bone resting on the margin of the acetab- 
ulum. Professor Hamilton would confine these partial luxations to those 
cases in which the bone does not completely clear the margin of the acetab- 
ulum, but rests on the cotyloid notch, after breaking down the transverse 
ligament; he has reported two cases, and Warren, of Boston, one, answering 
to this condition. The limb in each case was forcibly abducted and rotated 
outward, the head of the bone being distinctly felt anterior to the acetabulum. 
The patients were young. 
One luxation was replaced by the father of the boy; the other two remained 
unreduced. 
It is not improbable that in a feeble state of the general health, espe- 
cially in strumous children, the muscles about the hip-joint may become 
relaxed and the capsular ligament elongated, as is sometimes witnessed 
at the scapulo-humeral articulation, and thus may allow the head of the 
femui' to be displaced by a movement or force not sufficiently great to rup- 
ture the capsule; or the instances of the injury just noticed may have been 
pathological rather than traumatic. In other words, they may have arisen 
from arrested coxalgia, as suggested by Hamilton. At all events, until dis- 
section has removed the obscurity which overhangs this subject, everything 
connected with it must be mere conjecture. COMPLICATIONS OF HIP LUXATION. 
105 
Complications of Hip Luxation. 
Occasionally the force which dislocates the femur, by impelling the head 
of the bone against the side of the acetabulum, at the same time breaks away 
a portion of the edge of the articulating cavity, so that the bone, when re- 
duced, is constantly disposed to reluxation. When, after a dislocation of the 
femur and its reposition, this tendency in the head of the bone to escape 
from the cotyloid cavity is observed, it may be inferred that a fracture of 
this kind exists. 
The treatment of such an injury will consist in discovering, by different 
inclinations of the thigh, where the complicating lesion is situated, and then 
in maintaining the limb in a direction opposite to that which causes the dis- 
placement until nature has repaired the damage. 
Another complication of dislocation is fracture of the femur. The acci- 
dent is a rare one, and will be indicated by preternatural mobility of the 
limb, the movements at the same time not affecting the head of the bone. 
Two plans of treatment are open to the surgeon's choice. 
First, he may make an effort to reduce the dislocated head of the bone by 
properly-directed pressure, and, if successful in this, afterwards to sot the 
fracture. Mr. Birkett, in 1860, Bryant states, reduced with the greatest 
facility the head of the femur in a dislocation on the ramus of the pubes, in 
which the bone was broken, in a boy twelve years old. Other instances of a 
similar complication have been recorded by Bloxam, M. Eteve, Markoe, and 
others. 
When the luxation cannot be reduced, the fracture should be set so as to 
secure the best approximation of the fragments in their abnormal position, 
hoping that after consolidation has taken place and the continuity of the 
femur has been re-established, the head of the bone may be restored to its 
articulating cavity. 
Sii* Astley Cooper mentions a case in which this was accomplished by 
extension and counter-extension, five weeks after the injury, in a lad seventeen 
years of age. 
Old Dislocations of the Hip-Joint.-The exact length of time which 
should elapse after a dislocation before it becomes improper to attempt re- 
duction cannot be definitely determined. Sir Astley Cooper fixed the period 
at eight weeks; and to this opinion surgeons generally assent. 
The conditions which may be regarded as unfavorable to reduction are the 
following: 
First, immobility of the head of the bone.-When it is found firmly fixed in 
its position and but little affected by force applied to the thigh or the leg, it is 
an evidence that the adhesions are strong and well matured, and also that 
the inflammation that followed the injury was of a severe nature. 
Second, the position of the bone.-An old ischiatic or an obturator luxation 
will be less amenable to treatment than either a pubic or an iliac luxation. 
Third, the condition of the articulating cavity.-When the head of the femux* 
remains for some time out of its socket, both undergo important changes. 
The head loses its rotundity, becomes atrophied, flattened and roughened, 
and deprived of its cartilage. The acetabulum becomes shallow, partly by 
absorption and partly by fibrinous and osseous depositions. These changes 
take place slowly, but less so in the young than in the aged. 1 know of no 
way in which the state of the acetabulum-the more important of the two 
in its bearings upon this subject-can be fully ascertained. An exploring- 
needle might be used, but the information acquired in this way could scarcely 
be deemed trustworthy. 
Fourth, when the disability is not very marked.-In many cases of old 
femoral luxations, the head of the bone has fashioned for itself a new socket; 
and, while the movements of the limb must necessarily be abridged, the 
patient is not disqualified from taking exercise, or from following some 
occupation. 106 
DISLOCATIONS. 
Fifth, feeble health.-A person who is the subject of some serious organic 
trouble, or whose general health is impaired from any cause, is utterly dis- 
qualified to undergo the rude disruption of structures which is necessarily 
involved in the reduction of an ancient luxation. 
There are at least 29 cases recorded of old luxations of the hip which have 
been reduced at periods varying from six months to five years after the 
accident. 
When it is deemed wise to attempt the restoration of such a luxation, it 
should be commenced, after the administration of an anaesthetic, by manip- 
ulation, and completed, if necessary, by pulleys. 
In cases where the head of the bone, by pressing against an important 
nerve such as the ischiatic or the anterior crural, gives rise to much suffer- 
ing, or when, in consequence of the malposition of the limb, the patient is 
rendered peculiarly helpless, and it is deemed improper to resort to forcible 
efforts at reduction, a subcutaneous section of the bone might be made with 
great advantage. 
Accidents attending Reduction of the Hip-Joint. 
The accidents which may attend reduction of a dislocated femur are frac- 
ture of the bone, laceration or other injury of the sciatic nerve, and abscess. 
In one instance, Professor Pancoast, in attempting to reduce a luxation of 
the hip of three months' standing, fractured the thigh-bone.* The accident, 
instead of being a calamity, proved to be a decided advantage, as the patient 
in a few weeks was able to exercise with more facility and comfort than 
before the fracture. Mr. Hutchinsonf narrates a case in which the sciatic 
nerve was so seriously damaged, in reducing an ischiatic luxation, that 
permanent paralysis of the muscles endowed by its branches ensued. 
Abscesses have formed in the tissues disturbed by the head of the bone 
when the limb has been subjected to violent movements preparatory to re- 
duction. These have caused extensive disorganization of the soft parts, in 
consequence of their depth and diffusion. The collection of pus under such 
circumstances may be predicated upon the presence of pain, swelling, rigors, 
fever, and sweating. The exploring-needle would aid in the diagnosis; and 
when the existence of the abscess is established, it should be opened at the 
earliest moment and the purulent matter evacuated. 
Congenital dislocations of the hip-joint are very rare. They were first 
studied by Palletta, afterwards by Delpech, Dupuytren, Guerin, Pravaz, North, 
and others. Females are more commonly the subjects of this defect than 
males. Of the 45 cases collected by Dupuytren, 39 were females. 
The directions of these luxations are similar to those of cases occurring from 
ordinary causes, viz., on the dorsum ilii, on the pubes, and over the thyroid 
foramen. I have no knowledge of an ischiatic congenital dislocation. Con- 
genital dislocations may be bilateral. The most common form is that upon 
the dorsum ilii. 
The defect, in most instances, involves the head of the femur and the pelvic 
bones. The head and neck may remain undeveloped, the former being 
small, flat, or even absent, the neck being short, dwarfed, and changed in 
its direction. 
The acetabulum sometimes exists as an irregular, shallow cavity, without 
cartilage or ligaments, and dotted over with rough nodules of bone. At 
other times it is absent, or is indicated by an elevation, consisting of a 
shapeless accumulation of osseous masses. 
The synovial membrane may be present, retaining its usual attachments to 
Congenital Dislocations of the Hip. 
* Gross's Surgery, vol. ii. p. 108. 
f Medical Times, 1866, Bryant. DISLOCATIONS OF THE PATELLA. 
107 
the circumference of the rudimental cotyloid cavity, and to the neck of the 
femur, but greatly elongated. Or it may not exist as a capsule at all. The 
ligamentum teres becomes lengthened, and after years may disappear. The 
head of the bone, excluded from the normal acetabulum, forms for itself 
another, though a very imperfect one, on the dorsum of the ilium. The 
muscles participate in the vice: those which are not called into action shorten, 
waste, or undergo fatty degeneration ; and those upon which devolves an 
unusual amount of work become hypertrophied. 
The symptoms which declare a congenital dislocation or malformation may 
escape detection until the child begins to make its first essays at standing or 
walking; and even then, if the defect is bilateral, it may for some time escape 
observation. The most notable feature, that which will perhaps first attract 
attention, is the great length of the upper as compared with the inferior 
parts of the body, and the slender, undeveloped state of the muscles of the 
lower parts when contrasted with those of the upper extremities. The hips 
present an unusual breadth, owing to the elevated and prominent position of 
the great trochanters, the pelvis descending between the femurs. The gait 
is peculiar. The child moves forward with the chest thrown far back, the 
loins curved forward, the body rising on the ends of the toes, and alternately 
swaying from side to side as it advances. When in the recumbent position, 
the limbs are lengthened, in consequence of the weight of the body being 
removed from the articulations; and they can be drawn out or pushed up 
and shortened at pleasure, by alternate traction and upward pressure, 
without causing the child any uneasiness whatever. 
When the luxation is unilateral, it can be recognized by the limp in the 
gait, the high and prominent position of the trochanter major on the affected 
side when the child's weight rests on the limb, and, as time advances, by the 
lateral or compensating curve of the spine. 
Treatment.-The treatment of a case of congenital luxation of the hip- 
joint can only be palliative. Something may be done in the way of fixing as 
much as possible the femora. This is accomplished by encircling the pelvis 
with a strap, so constructed as to press the great trochanters towards the 
innominate bones. In two cases of this deformity which came under my 
care, considerable benefit was derived from such an arrangement. 
It has been proposed, by means of deep subcutaneous incisions and a 
systematic combination of movement and rest, to condense the tissues 
around the head of the bone, so as to circumscribe its motions. This plan 
has been practiced, but partakes too much of the nature of a forlorn hope 
to receive any special commendation. 
It will be best, in cases of this defect, to enforce, as much as possible, the 
sitting posture and cold bathing, and, when the patient is old enough to 
manage an apparatus, the Darrach wheel-crutch will be found, in walking, to 
answer an excellent purpose. 
There are five directions in which the patella may be dislocated, namely, 
outward, inward, vertically (or on its axis), upward, and downward. These dis- 
placements may be either partial or complete. They are all quite uncommon 
accidents. 
DISLOCATIONS OF THE PATELLA. 
Dislocation Outward.-In examining the anatomical peculiarities of the knee, 
the external dislocation would seem to be the least probable. That part 
of the trochlear surface furnished by the femur for the play of the patella 
is high, and the ascent more abrupt on the external than on the internal 
condyle. There is, however, a peculiarity of the quadriceps extensor cruris 
muscle, in the tendon of which the patella lies, that explains the greater 
tendency of the bone to external luxation. The tendo patella? and the quad- 108 
DISLOCATIONS. 
riceps muscle are attached to the patella at an angle the vertex of which 
is directed towards the internal condyle. This is very noticeable if, when 
making a ligamentous preparation of the knee-joint (Fig. 989), the rectus 
femoris muscle be preserved and examined. 
In forcible contractions of the quadriceps muscle, the tendency is to convert 
the angle into a straight line; in doing so the patella is strongly and rapidly 
swept across to the outside of the articulation. The mechanical effect is not 
unlike that which follows the action of the digastric muscle,-rapidity of 
movement at the expense of power. 
When the dislocation is &> partial one, the inner surface of the patella rests 
upon the articular surface of the external condyle of the femur (Fig. 990), 
the ridge of the former lying beyond the articular surface of the latter. The 
resulting obliquity in the position of the patella turns its external border 
forward, and turns its internal border into the notch between the condyles. 
When the luxation is complete, the articular surface of the bone lies against 
the outer surface of the external condyle, its inner edge presenting itself 
forward. (Fig. 991.) In both dislocations the synovial sac is ruptured, 
Fig. 989. 
Fig. 990. 
Fig. 991. 
Angle occupied by the patella 
between the rectus femoris muscle 
and the tendo patella;. 
Incomplete external dislocation of 
the patella. 
Complete external dislocation of 
the patella. 
and some of the fibres of the capsule and of the tendo patellse are torn. 
Mr. Mayo mentions a singular instance of luxation, in which the inner 
border of the patella rested against the outer surface of the external condyle 
of the femur. 
Causes.-The most common cause of this luxation is muscular action, ex- 
erted when the limb is in certain favoring postures, as in dancing or in leaping, 
or when the thigh is subjected to a violent outward twist, the leg being at 
the same time fixed. The bone may also be displaced by direct violence done 
to the part. 
There are certain peculiarities connected with the conformation of the limbs, 
such as genu valgus, or " knock-knees," which favor the production of this dislo- 
cation. Traumatic injuries to the internal lateral ligaments of the knee-joint, 
or alteration of their structure from pathological changes, by allowing an 
inward inclination of the knee, are also predetermining causes. 
Symptoms.-The breadth of the knee is increased; the internal condyle 
becomes unusually prominent; the limb is a little flexed, and the joint fixed. 
If the luxation is partial, the external border of the patella can be felt 
projecting anteriorly; if complete, both borders can be recognized, the ex- 
ternal posteriorly, and the internal anteriorly, in front of the external con- DISLOCATIONS OF THE PATELLA. 
109 
dyle. The tension of the quadriceps muscle and of the tendo patelite on the 
external side of the limb, and the flatness of the tissues on the internal side, 
are quite noticeable. 
Treatment.-The reduction is most conveniently effected by placing the 
patient on his back, in a semi-recumbent position, after which the surgeon, 
taking his seat on the edge of the bed, by the side of the injured limb, with 
his face towards that of the patient, relaxes the quadriceps extensoi* cruris 
muscle. This is done by placing the heel of the injured limb upon bis shoulder. 
Then, if the luxation is incomplete, he presses the patella inward with his 
thumb and fingers; if the luxation is complete, he presses it forward and 
inward, w'hen the bone will resume its normal position. 
Some tenderness and swelling will follow the reduction, but usually these 
are of transient duration. There are instances, however, in which the acci- 
dent has been followed by high inflammation of the joint, and even by death, 
as in the case recorded by Mr. Key, of London, in which suppuration of the 
articulation supervened. 
Dislocation Inward.-The infrequency of this displacement will appear 
from the fact that not more than four or five cases have been recorded. 
M. Putegnot has reported a case of complete dislocation of both patellae 
inward.* 
The causes of the accident are muscular action and direct violence. 
The luxation may be incomplete or complete. 
In the first variety, the bone is found resting against the articulating sur- 
face of the internal condyle, with its internal edge directed forward. (Fig. 
992.) In the second or complete form, the bone is entirely displaced from 
the articulating face of the condyle, and placed on the inner surface of the 
latter, its edges facing antero-posteriorly. (Fig. 993.) 
Treatment.-The surgeon and the patient are to assume relatively the 
same positions as in the reduction of an external luxation, when the bone is 
to be pressed outward if the displacement is partial, and forward and outward 
if it is complete. 
Vertical or Axial Dislocation.-This remarkable luxation is of very rare 
occurrence. Hamilton has been able to collect only twenty-four examples 
Fig. 992. 
Fig. 993. 
Fig. 994. 
Incomplete dislocation of the patella 
inward. 
Complete dislocation of the patella 
inward. 
Vertical luxation of the patella. 
of the injury. The displacement of the bone may be vertical, or the bone 
may undergo a semi-revolution on its axis. 
* Malgaigne, Treatise on Luxations, p. 919. 110 
DISLOCATIONS. 
In the vertical luxation, one edge of the bone rests in the groove between 
the condyles of the femur, and the other is directed forward. (Fig. 994.) 
The bone, according to Malgaigne, may rotate either from within outward 
or from without inward. 
In the second variety, the patella is turned completely over, the surfaces 
of the bone exchanging places, the cutaneous surface resting on the trochlea) 
of the condyles, and the articular surface being turned towards the skin. It 
is difficult to understand the mechanism of this dislocation. It probably 
commences as a lateral displacement. 
Symptoms.-The leg is extended. The edge of the patella can be recog- 
nized under the skin in front of the knee. The extensor muscles are in a 
state of tension, and over each condyle there is a marked depression. The 
pain accompanying the dislocation is very severe. 
Treatment.-This luxation is often exceedingly difficult of reduction. 
The resistance is supposed to arise from the firmness with which the bone is 
held in the groove of the trochlear surface of the femur by the contraction of 
the quadriceps extensor muscle. I do not think, however, that this is suffi- 
cient to explain the difficulty experienced in dislodging the bone from this 
locality; for, even when the tendon of this muscle has been divided, as was 
done in two instances, once by Dr. Gazzam, of Pittsburg, and once by Dr. 
Woolf, the obstacle to the reposition was not overcome. We must therefore 
look for some other explanation than the one commonly advanced. This, I 
think, will be found in the existence of a slit made in the fibrous tissue of 
the capsule, in which the patella is imbedded, and through which the an- 
terioi* edge of the bone slips at the time luxation occurs. 
In reducing the bone, an anaesthetic should be first administered. In order 
to relax the extensoi* muscle in front of the limb as much as possible, the 
thigh must first be flexed on the abdomen. Then, while an assistant is 
directed to alternately flex and extend the leg, the surgeon, with his thumbs 
placed on the opposite surfaces of the bone,-the one near to its lower edge 
and the other near to its upper edge,-makes strong pressure in opposite 
directions. The reduction will most probably follow. 
Another method consists in raising the limb and making rapid and for- 
cible extension of the leg, placing a hand in the ham to serve as a fulcrum. 
In a case of vertical luxation of the patella occurring in a negro during 
convulsive attacks, Dr. Boyd, of Thornton, Indiana, attempted reposition 
and failed. During a recurrence of the convulsions, two weeks later, the 
dislocation was reduced spontaneously. Malgaigne records a similar case 
of spontaneous reduction, which took place while the patient was walking. 
When the patella makes half a revolution on its axis, its cutaneous surface 
becomes the lower one,-a complete dislocation. The articular facets may be 
distinguished beneath the skin. The reduction must be made by flexing 
the thigh on the pelvis, extending the leg, and grasping the borders of the 
bone between the thumb and fingers, dragging it forward at the same time 
that it is turned or rotated in the direction opposite that of the displacement. 
During this manipulation the knee should be flexed and extended. It was 
somewhat after this method that M. Castara* reduced a complete dislocation 
of the patella. 
After the reduction of a dislocated patella, the knee, covered with a cold 
anodyne lotion, should be placed upon a posterior splint, and kept quiet for 
eight or ten days. Afterwards gentle movements of the joint may be allowed. 
As a prudential measure, a flannel roller should be worn around the articula- 
tion for several weeks after the patient commences to walk about. 
Dislocation Upward.-Upward luxation of the patella can only occur as 
a result either of pathological elongation or of rupture of the ligamentuni 
patellse. The luxations of this kind may, therefore, be divided into patho- 
logical and traumatic. Fracture at the apex of the bone has been confounded 
* Malgaigne, t. ii. p. 918. DISLOCATIONS OF THE KNEE. 
1ll 
with this injury. The traumatic form may be produced by leaping oi* 
falling. 
The signs of the dislocation are very much the same as those of fracture, 
namely, retraction of the patella, flattening of the knee, and inability to ex- 
tend the leg. But it may be distinguished from fracture by the fact that 
only a single piece of bone can be detected, whereas in fracture two fragments 
will be found, one joined to the tendon below the knee and the other to the 
muscle above the joint. 
When the upward luxation is produced by structural changes in the liga- 
ment itself, or by disease of the joint, the displacement is a gradual one; 
when it arises from rupture, it is sudden or immediate. 
Treatment.-The treatment for traumatic luxation is the same as that 
for fracture of the patella, namely, moderate elevation of the limb, a posterior 
splint, and adhesive plasters applied so as to approximate the divided ends of 
the tendon. 
Pathological cases can only be remedied in so far as the diseases which 
produce them are amenable to treatment. 
Dislocation Downward is traumatic in its origin. It can only be caused 
by violent muscular action, in which the quadriceps extensor cruris is torn 
immediately above the tendinous capsule of the patella, allowing the bone 
to descend towards the tibia. 
The signs of the accident consist in the existence of a marked depression a 
short distance above the front of the knee-joint, with two prominences, one 
below, formed by the patella, and one above, caused by the retraction of the 
quadriceps muscle. The limb cannot be extended, and the injury is followed 
by considerable swelling. 
The treatment is the same as that directed for upward displacement. 
Congenital dislocations of the patella have been observed a number of 
times. The most remarkable cases are those recorded by Dr. Caswell,* of 
Providence, Rhode Island. Five members of one family, extending over 
three generations, had double congenital dislocations of the patella. 
DISLOCATIONS OF THE KNEE. 
The infrequency of this dislocation is the best evidence of the perfection 
of a mechanism in which, for the fulfillment of its function, it was requisite 
that the articulation should be so constructed as to harmonize the easy, 
graceful movements displayed in walking with the possession of great- 
strength. The articular surfaces, accordingly, are extensive, and so ar- 
ranged that they do not move in parallel planes. Not only are the liga- 
ments very powerful, but they occupy the interior as well as the exterior 
of the joint, while in front the patella, with its muscle and tendon, gives 
an additional security to the articulation. 
There are four principal luxations of the tibio-femoral joint, namely, back- 
ward, forward, and two lateral. These may be partial or complete. There is 
also a variety of dislocation which may be classed as a luxation by rotation. 
Dislocation Forward.-This luxation is generally complete. In a collec- 
tion of 26 cases made by Malgaigne, only two were incomplete. In this 
injury, the tibia is carried in front of the femur, the spinous process on the 
head of the former resting in the notch of the trochlear surface of the femur. 
Or the tibia may overlap the femur to a much greater degree. (Fig. 995.) 
A displacement of this nature involves a very extensive and serious laceration 
of the ligaments and other structures about the joint. The dissections which 
have been made of this injury have revealed a rupture of one or other of 
the crucial ligaments, also of the fibrous involucrum of the joint, derived from 
the vasti muscles, together with rupture, partial or complete, of the heads of 
* Hamilton on Fractures and Dislocations, 5th edit., p. 822. 12 
DISLOCA TIONS. 
the gastrocnemius and biceps flexor cruris muscles. The patella lay in a de- 
pression above the head of the tibia. The popliteal vessels and nerve appear 
to have escaped any serious injury. 
The causes which determine this luxation are such as act either on the 
foot or on the thigh when the joint is in a flexed 
position. In the one case the bones of the leg are 
impelled forward, and in the other the femur is 
forced backward. In whichever way the luxation 
is produced, there is usually joined to the flexion a 
torsion or twist of the leg. 
Symptoms.-The leg is shortened from one and a 
half to three inches, and it may be either extended 
or slightly flexed, depending on the injury to the 
gastrocnemius muscle. Two prominences are seen, 
one in front of the knee, formed by the head of the 
tibia, and one behind, in the ham, formed by the 
condyles of the femur. These prominences may be 
satisfactorily recognized by the touch ; in them the 
outlines of the tuberosities and the condyles of the 
respective bones can be distinctly traced. The 
patella may lie either in front of the tibia, or in a 
depression above the head of the latter. In eithei* 
case it is quite movable, in consequence of the re- 
laxation of the quadriceps muscle. The leg is gener- 
ally found rotated in either an outward or an inward 
direction, according as the biceps muscle does or does 
not retain its hold upon the head of the fibula. 
Treatment.-Place the patient upon his back on a hard mattress, and ad- 
minister ether. Apply a counter-extending band to the thigh, and an ex- 
tending band to the leg above the ankle, intrusting both to assistants, who 
are to make steady and strong traction while the surgeon, with his arm or 
knee underneath the joint, forcibly flexes the leg. 
Fig. 995. 
Anterior dislocation of the leg. 
Dislocation Backward.-This dislocation, though not uncommon as a result 
of disease, is extremely rare as a traumatic injury. The head of the tibia is 
carried either partially or entirely behind the condyles of 
the femur. (Fig- 996.) 
The posterior ligament is lacerated, the heads of the 
gastrocnemius, popliteus, and quadriceps muscles, to- 
gether with the popliteal vessels, are placed upon the 
stretch, and in one case the artery has been torn. In 
Malgaigne's collection of posterior tibio-femoral luxations, 
-twelve in number.-six were partial and six complete. 
The luxation is produced by a force acting either in 
front of the leg when the thigh is fixed, or behind the 
latter when the leg is immovably fixed. 
Symptoms.-The leg is shortened and bent forward or 
extended. A depression exists in front of the joint. The 
rounded condyles of the femur can be seen and felt ante- 
riorly, and the head of the tibia is found projecting into 
the ham. 
Treatment.-The reduction is effected by making ex- 
tension and counter-extension from the ankle and thigh, 
as in the former luxation, the surgeon forcing the leg into 
a state of flexion, with his knee or arm acting in the ham. 
When the articular surfaces are not entirely separated, 
the reposition may be accomplished without the employment of extending 
and counter-extending forces, by the surgeon raising the thigh, placing his 
arm behind the joint, and forcibly flexing the leg. 
Fig. 996. 
Posterior dislocation of 
the tibia. DISLOCATIONS OF THE KNEE. 
113 
Lateral Dislocations are either external or internal. They occur with about 
equal frequency. Although they are met with of all degrees, they are, never- 
theless, rarely complete. 
In the inward dislocation, the head of the tibia is carried inward, so that 
the internal condyle of the femur rests upon the outer side of. the internal 
articular surface on the head of the tibia, or upon its external articular sur- 
face, or upon the ridge separating the two. (Fig. 997.) 
The lateral ligament will be torn to a greater or less degree, according to 
the amount of the displacement. And it 
is more than probable that the crucial 
ligaments will participate in the lacera- 
tion. 
When the dislocation is outward, the 
head of the tibia is carried in an ex- 
ternal direction, the external condyle 
of the femur occupying either the inner 
portion of the outer articular surface 
of the head of the tibia, or the inner 
articular surface, or the ridge between 
the two. (Fig. 998.) 
The lateral and crucial ligaments 
will sustain a damage similar to that 
caused by the internal displacement. 
The patella will also be luxated in the 
same direction. 
The lateral luxations require for their 
production forces which act laterally 
and simultaneously, in opposite direc- 
tions, upon the thigh and upon the leg. 
Symptoms.-The signs of the lateral 
displacements are quite obvious. When the luxation is inward, the knee-joint 
will present a marked increase in its transverse diameter. A hard, round 
tumor-the internal tuberosity of the tibia-will be seen and felt on the 
inner aspect of the joint, producing a marked fullness with a depression 
above. On the outer side, an unusual prominence-the external condyle of 
the femur-will also be noticed, with a depression below. The limb is not 
shortened, but generally is somewhat twisted on its axis, so that the spine of 
the tibia does not present antero-posteriorly. This is due more to the resist- 
ance of certain untorn portions of the ligaments than to muscular tension. 
When the dislocation is outward, the same prominences exist on the outer 
and inner aspects of the articulation as are seen in the inner displacement, 
the difference being that the fullness witnessed on the inner side of the knee 
is due to the presence of the internal condyle, and that on the outer side to 
the external tuberosity of the tibia. 
Treatment.-These-dislocations are reduced without difficulty, requiring 
only extension and counter-extension, the thigh and the leg being pressed in 
opposite directions. 
In all dislocations of the knee, after the bones have been replaced, the 
joint should be immobilized, by suspending the limb in a fracture-box, and 
applying frequently, for the first few days, cold lotions of lead-water and 
laudanum. If the inflammatory symptoms run high, attended by much 
swelling, heat, and tenderness of the articulation, they must be moderated 
by leeches and a purge, followed by the neutral mixture, containing a small 
amount of morphia. 
After subsidence of the inflammation, gentle movements of the joint ought 
to be practiced, so as to prevent stiffness. Walking cannot be attempted 
for two or three weeks, and then only with the assistance of crutches. 
The articulation will remain weak, stiff, and insecure for a long time, and 
may never recover its former usefulness. 
VOL. II.-8 
Fig. 997. 
Fig. 998. 
Incomplete internal 
luxation of the bones 
of the leg. 
Incomplete external 
luxation of the bones of 
the leg. 114 
DISLOCATIONS. 
External Rotatory Dislocation.-A very unusual dislocation of the bones 
of the leg is occasionally seen, in which the tuberosities of the tibia fall 
antero-posteriorly in addition to being displaced externally. In this rare 
form of luxation the bones of the leg are twisted so that the internal angle 
of the tibia looks directly forward, and the fibula is directed backward. 
The tuberosities of the tibia are 
placed antero-posteriorly, the ex- 
ternal condyle of the femur resting 
in the notch between (Fig. 999). 
A very interesting case of this 
luxation came under the care of 
Dr. Levis at the Pennsylvania 
Hospital. The accident can only 
occur by the leg being violently 
twisted while the thigh remains 
fixed. 
Symptoms.-A marked promi- 
nence of the patella is seen exter- 
nally, the internal condyle of the 
femur is also very prominent, and 
the inner border of the calf of 
the leg presents anteriorly. The 
spine of the tibia can also be felt 
directed exteriorly instead of an- 
teriorly (Fig. 1000). 
Treatment.-The reduction is 
accomplished by making exten- 
sion from the leg and counter- 
extension from the thigh, at the 
same time twisting the leg inter- 
nally or in a direction opposite to the displacement. After the reduction the 
joint should be kept at rest, and the inflammation controlled by cold anodyne 
lotions. At the end of twelve or fourteen days passive motion must be 
made in order to prevent undue stiffness. The limb will remain weak for 
a long time after such an accident. 
Fig. 999. 
Fig. 1000. 
External rotatory dislo- 
cation of the leg. From a 
cast taken at the Pennsyl- 
vania Hospital. 
Relation of the bones of 
the leg to the femur in an 
external rotatory luxation. 
This singular displacement is due to rupture of the coronary ligament, 
allowing one of the semilunar cartilages to move forward during the motion 
of the joint, and to be caught between the femur and the tibia. The internal 
cartilage is the one generally displaced. 
This peculiar derangement of the cartilages was first described by Mr. 
Iley. It generally occurs suddenly, caused by a twist of the leg when the 
limb is in a state of flexion, and is accompanied by pain and inability to 
extend the leg. The true nature of the injury is frequently overlooked. In 
one instance a young man was brought to me from a neighboring State, 
who, four weeks previously, while on his knees, suddenly experienced a 
severe pain in the knee-joint, and at once found it impossible to straighten 
the leg. Various applications had been used to remove the stiffness, which 
was supposed to be due to a sprain. A few moments enabled me perfectly 
to restore the functions of the joint. In a second case, a lady, while playing 
with a kitten on the floor, in a moment found both knees become locked, so 
that she was unable to regain her footing. She had been some time in this 
situation when I saw her, but was cured without the least difficulty. In a 
third and a fourth case, both females, the derangement had followed an acci- 
dent, in which the patients were thrown from a carriage, several weeks 
before they came under my observation. 
Treatment.-When much pain is experienced, it is best to administer an 
Displacement of the Semilunar Cartilages. CONGENITAL DISLOCATIONS OF THE KNEE-JOINT. 
115 
anaesthetic before attempting reduction. As soon as the patient is rendered 
insensible, carry the limb first to extreme flexion over the knee, and then 
suddenly extend it. 
Or, if the anaesthetic is not given, the reposition can readily be accom- 
plished by setting the patient at the end of a table, with the leg hanging 
down. Then, grasping the leg above the ankle, make strong extension, at 
the same time bending this part of the limb under the table, afterwards 
bringing it forward to the position of extension. 
The reduction may also be secured by flexing the limb round a bed-post, 
and then extending it. 
Very little after-treatment is necessary. In a few days the function of 
the joint will be restored. But, as there is a tendency to the reproduction of 
the derangement, the patient should be cautioned to be circumspect with 
regard to certain movements, especially those of strong flexion. He may 
also, with advantage, employ a flannel bandage or a laced knee-cap about 
the knee. 
Complicated Dislocations of the Knee. 
The complications possible in luxations of the knee are fracture, rupture 
of the popliteal vessels, and an external wound exposing the joint. Wells, of 
Columbia, South Carolina, witnessed a case of luxation of the knee in which 
the internal tuberosity of the tibia was broken. The nature of the injury 
was disclosed on a post-mortem examination, the patient having died from 
causes independent of the injury. 
A complication of this kind could only be determined by the presence of 
crepitus and of mobility; and it would require that the detached piece should 
be pressed into position, should its return not follow the reduction of the 
bone. 
Rupture of the popliteal vessels has occurred in three cases, two of which 
have been noticed by Mr. Lowe. An accident of this kind will require 
amputation. 
Compound dislocations of the knee-joint are among the most serious accidents 
which can befall the human body. The complication arises from the presence 
of an open wound, communicating with a large and complex joint, the in- 
flammation of which exposes the patient to the risks of erysipelas or pyaemia; 
or, if these are escaped, he is exposed to an exhausting suppuration, or to 
necrosis of the bones. Whether the antiseptic treatment will, after a more 
extended trial, modify our views in regard to the management of these 
cases, remains yet to be determined. Certainly, in the light of our present 
experience, no injuries more imperatively demand amputation than these. 
If the patient is young and possesses a sound constitution, and if, in addi- 
tion, the blood-vessels have escaped uninjured and the soft parts are not 
extensively lacerated, resection may be substituted for amputation. 
Congenital Dislocations of the Knee-Joint 
Congenital dislocations of this articulation have occasionally been observed 
affecting sometimes one knee, and at other times both knees. Like the ordi- 
nary luxations, they may be complete or incomplete, and may occur in the 
same directions. 
The dislocation forward is said to be the most common. 
In some cases, much benefit has followed the application of splints and 
bandages, after reduction of the displaced bones. The case recorded by Dr. 
Bard, of Troy, New York, seems to have been cured by this plan, as also one 
reported by Dr. Youmans.* 
When displacement constantly follows the reposition of the luxation, 
tenotomy may be employed with a favorable result. By this operation 
® Hamilton, Treatise on Fractures and Dislocations, 5th ed., p. 823. 116 
DISLOCATIONS. 
Hamilton measurably corrected a case of congenital dislocation of both tibiae 
backward. If the articulating surfaces of the bones forming the joint can, 
by mechanical measures, be retained in contact for a sufficient time, as the 
growth of the body advances the injured limb may be rendered but little 
inferior in usefulness to its fellow. 
DISLOCATIONS OF THE FOOT OR ANKLE. 
These dislocations are described by Sir Astley Cooper, Malgaigne, and 
Hamilton as luxations of the bones of the leg. As there can be no reason 
for departing from the order observed in the classification of the displace- 
ments of the other joints, I shall adhere to the nomenclature which I have 
hitherto preserved in the treatment of this class of injuries, regarding the 
foot as the part dislocated. 
Luxation of the ankle, except as a sequence of a fracture of one or other 
of the malleoli, is not a common accident. The secure manner in which the 
astragalus is let in between the malleoli, and the strength of the lateral and 
posterior ligaments, are inimical to displacement. 
Dislocation of the foot may occur in four different directions,--forward., 
backward, and laterally {outward or inward). 
Dislocation Forward is commonly produced by a violent force acting on 
the front of the leg when the foot is fixed. Or it may be caused by a fall 
upon the heel when the tarsus is flexed. 
The luxation may be partial or complete. Like the lateral displacements, it 
is liable to be accompanied by fracture of one or both malleoli. Only foui- 
cases have been recorded. 
In this dislocation, the lateral and anterior ligaments are ruptured. The 
astragalus escapes from the mortise-like cavity between the tibia and the 
fibula. If the luxation.is complete, the tibia 
rests on the top of the calcaneum. (Fig. 
1001.) If the luxation is incomplete, only a 
portion may lie posterior to the joint. A 
singular example of incomplete dislocation 
of the foot is recorded by Mr. Poland, in 
which the posterior part of the astragalus 
became wedged between the malleoli so 
firmly that it could not be reduced. 
Symptoms.-The foot is lengthened from 
one to two inches. The heel is short- 
ened. The malleoli are felt lower down 
than usual ; and the projection of the 
tendo Achillis disappears, the latter lying 
in contact with the posterior surface of the tibia. 
Treatment.-To reduce this luxation, the leg must first be flexed to a right 
angle with the thigh, in order to relax the gastrocnemius and soleus muscles. 
After this is done, extension should be made from the foot, and counter-ex- 
tension from the knee, the surgeon drawing the bones of the leg forward at 
the same time that he forces the foot backward. 
When more than ordinary opposition is encountered, the reduction may 
be facilitated by the administration of an anaesthetic, or by the subcutaneous 
division of the tendo Achillis. 
In an old case of forward dislocation of the foot which I once witnessed, 
the disability entailed by the malposition of the bones was not very marked, 
though the motions of the ankle were considerably abridged. 
After the bones have been replaced, a fracture-box, or lateral splints, em- 
bracing the foot, ankle, and leg, and secured by a roller, will ordinarily furnish 
the necessary support. 
Fig. 1001. 
Dislocation of the foot forward. DISLOCATIONS OF THE FOOT OR ANKLE. 
117 
Dislocation Backward is produced by the backward propulsion of the foot 
while it is in the extended position. The accident is more readily produced 
if at the same time a counter-force is in operation against the posterior part 
of the leg. 
When the luxation is complete, the lateral and anterior ligaments of the 
ankle are torn, and the bones of the leg are placed in front of the astragalus 
(Fig. 1002), the tibia resting in contact with the scaphoid bone; when the 
luxation is incomplete, it rests upon the neck or head of the astragalus. 
The luxation is generally accompanied by a fracture of the fibula and the 
malleolus of the tibia. Several dissections have been made to establish the 
existence of this complication. Sir Astley 
Cooper mentions two,-one by Mr. Tyrrel 
and the other by Mr. Douglass,-in both 
of which the lower end of the fibula was 
broken. Mr. Adams details the lesions ob- 
served in another case, in which, in addition 
to the fracture of the fibula, the malleolus 
of the tibia was broken. 
Symptoms.-The signs of this injury are 
quite characteristic. The foot is shortened; 
the heel lengthened and elevated; and the 
toes, by the contraction of the muscles of 
the calf of the leg, are turned down. The 
tendo Achillis, being carried back with the 
heel, stands off very prominently from the 
posterior part of the leg. 
Treatment.-The measures adopted for 
reduction of the forward dislocation are 
equally efficacious here, namely, flexing the leg to a right angle with the 
thigh, and making extension from the foot and counter-extension from the 
knee, while the bones of the leg and the foot are forced by the surgeon's 
hands in opposite directions. 
This dislocation is generally more difficult to reduce than the one forward, 
and sometimes manifests a great disposition to reluxation. When this is the 
case, the division of the tendo Achillis constitutes the best remedy, and should 
always be adopted. In a case of this dislocation which showed a tendency 
to recur, I was enabled to resist the displacement by applying a weight to 
the front of the leg for a short time. 
After the reduction, the limb should be placed in a fracture-box and sus- 
pended. If this dressing proves unsatisfactory, the apposition of the bones 
can be maintained with greater certainty by applying to the ankle a plaster 
roller, which, when it becomes hardened, constitutes a secure case for the 
joint. But the precaution must always be taken to observe that the dressing 
does not become too tight from swelling. 
If the inflammation following the injury be very marked, it may be neces- 
sary to apply leeches and anodyne lotions over the joint. 
Fig. 1002. 
Dislocation of the foot backward. 
Dislocation Outward is caused by any violence which forces the foot into 
a state of extreme abduction, in which position, the internal lateral liga- 
ment being ruptured, the astragalus impinges against the external malleolus 
with such force as to cause a fracture a short distance above this process 
(Pott's fracture). (Fig. 1003.) In some instances, if the internal lateral liga- 
ment does not yield, the astragalus acts the part of a fulcrum, and the 
extremity of the internal malleolus is likewise broken off. Several times 
have I seen compound outward dislocations of the foot. 
Symptoms.-The signs of this accident are quite apparent. There is an 
unusual projection of the internal malleolus, beneath which may be felt the 
tibial surface of the astragalus. The foot is very much everted, its inner 
surface resting upon the ground and its outer surface directed upward, while, 118 
DISLOCATIONS. 
two or three inches above the outer malleolus, an indentation may be dis- 
covered, which marks the seat of the fracture of the fibula. (Fig. 1004.) 
Treatment.-The plan of treatment is the same as that employed in the 
management of a case of Pott's fracture; that is, after bringing the foot 
Fig. 1004. 
Fig. 1003. 
Fracture at the lower fifth of 
the fibula, with the attendant 
deformity,-Pott's fracture. 
Dislocation of the foot outward, with fracture of the fibula. 
into a state of adduction, to apply along the inner side of the leg a splint 
which will extend from a little below the knee to three inches beyond the 
foot. A wedge-shaped pad is attached to the splint three inches above its 
lower end, with its base downward, and so applied that it will rest against 
the inner ankle. The upper end of the splint is secured to the leg, above the 
calf, by a few turns of the bandage. The foot is then fastened at the lower 
end by a figure-of-eight roller of the ankle. (See Pott's fracture.) 
Dislocation Inward.-This luxation is by no means so common as that out- 
ward : and when it does occur it is generally marked by severe concomitant 
injuries, such as fracture of the fibula, contusions, and often an external wound. 
Of 22 dislocations of this kind analyzed by Malgaigne, 19 were compound. 
The causes producing this luxation are such as forcibly adduct or invert 
the foot,-e.g., falls sustained upon its outer border, during which the external 
lateral ligament is torn and the astragalus rotated outward. It appears that 
in this luxation, according to Malgaigne, fracture is not so common as in the 
outward dislocation. In the 22 cases collected by this writer, 8 were unat- 
tended by fracture of either the tibia or the fibula; 4 were accompanied by 
fracture of the fibula; 2 by fracture of the tibia; and in 1 the astragalus 
was broken. 
Symptoms.-The foot is inverted, its outer border resting on the ground, 
and the external malleolus projecting beneath the integuments. (Fig. 1005.) 
Treatment.-The bones are restored to their proper relations by grasping 
the foot and carrying it outward until it is in a proper line with the bones 
of the leg, after which the fracture-box will serve to maintain the parts in 
position. 
Sometimes cases are encountered in which considerable difficulty is expe- 
rienced in effecting the reduction, particularly in those forms of the injury COMPOUND DISLOCATIONS OF THE ANKLE. 
119 
which partake of the character of a true dislocation, and where it becomes 
necessary to employ more than ordinary force. In such cases, to insure 
the least resistance from the antago- 
nism of the muscles, and to derive the 
fullest advantage from traction, the leg 
must be flexed to a right angle with the 
thigh. A counter-extending band is 
placed around the thigh, and an ex- 
tending band secured to the foot, after 
the manner of the Barton handkerchief. 
Extension and counter-extension being 
made, the surgeon aids the reposition 
Fig. 1005. 
Fig. 1003. 
Dislocation of the foot inward. 
Dislocation of the astragalus 
upward. 
by making such movements of the foot and applying such pressure as will 
tend to force the parts into place. The use of an anaesthetic will further 
contribute to the success of these measures. 
When there is a tendency to a recurrence of the displacement, and the 
fracture-box is found not to answer, the difficulty may be overcome by flex- 
ing the leg and placing upon its internal surface an angular splint (vol. i. 
Fig. 387), which should extend seven or eight inches above the knee, and 
support likewise the foot. 
A very rare form of injury at the ankle-joint is one in which the astragalus 
is forced upward, separating the tibia and fibula from each other, and lodging 
in the interspace. This has been designated by Nelaton a luxation of the foot 
upward. 
The signs of this displacement are a marked increase of the intermalleolar 
space, imparting an unusual breadth to the ankle, and a sinking down of the 
malleoli towards the borders of the foot. (Fig. 1006.) The foot can be freely 
flexed and extended. 
The astragalus is restored to its proper position by extension and counter- 
extension, after which the tibia and fibula must be bound together, and the 
limb placed in a fracture-box until the inferior peroneo-tibial ligaments have 
become reunited. 
These are injuries of great severity and gravity. Compound dislocations 
Compound Dislocations of the Ankle. 120 
DISLOCATIONS. 
are more commonly met with at the ankle than at any of the other joints. 
The external wound is generally situated at the inner aspect of the joint. 
(Fig. 1007.) It is made by the lower ex- 
tremity of the tibia, this bone not unfrcquently 
projecting through the rent in the soft parts. 
Treatment.-At one time, amputation was 
deemed the only proper measure in a case of 
this nature. A larger experience, however, has 
shown that in most cases of this injury a more 
conservative course may be adopted, with a 
reasonable prospect of saving the limb. 
The conditions which will render amputa- 
tion necessary after a compound luxation of 
this joint, are a very extensive laceration of the 
soft parts, a bad state of the constitution, and 
rupture of the principal blood-vessels. The 
latter lesion, under any circumstances, will be 
a sufficient reason for the operation. 
When, however, the patient possesses a sound 
body and the blood-vessels remain uninjured, 
an effort should always be made to save the limb. When the bones protrude, 
their ends should be excised; but, if they do not protrude, it is better to allow 
them to remain undisturbed, since the damage inflicted on the surrounding 
tissues by a forced dislocation for the purpose of excision will do more harm 
than can be compensated for by the operation. 
The wound may be dressed either antiseptically or by irrigation, its edges 
having been loosely supported by two or three stitches of silver wire. To 
secure as perfect immobility as is possible ought to be the chief aim of the 
surgeon. This can be most conveniently done by suspension, either in a 
fracture-box or in a wire splint. 
Fig. 1007. 
Compound dislocation of the ankle-joint. 
FIBULAR OR PERONEO-TIBIAL LUXATIONS. 
The fibula may be displaced from the tibia at its upper or its lower 
extremity. Displacement at the upper extremity is called superior peroneo- 
tibial, and at the lower, inferior peroneo-tibial luxation. They are both un- 
common injuries. 
Dislocation of the Upper Extremity.-This displacement may be forward 
or backward. There are five recorded examples of the forward dislocation. 
Of these, Malgaigne furnishes three, Thompson one, and Hamilton, one. Of 
the second, or backward dislocation, Dr. Joseph G. Richardson has reported 
one case,* and Malgaigne one. 
The injury may follow either direct force or great muscular exertion. The 
anterior and posterior peroneo-tibial ligaments are torn, and the head of the 
bone slips forward or backward, according to the direction in which the dis- 
locating force is received by the bone. 
Symptoms.-The movable extremity of the fibula and the tendon of the 
biceps muscle may be felt out of their proper position, and the limb is unable 
properly to support the weight of the superincumbent body. 
Treatment.-To return the fibula to its place, it is necessary first to flex 
the leg, so as to relax the biceps muscle ; and then to press the bone in the 
proper direction. 
To insure the permanence of the reduction, the limb should be maintained 
in that position which favored the reposition, until the fibula has contracted 
adhesions sufficiently strong to hold it in place. 
There is a relaxation of the ligaments of the superior peroneo-tibial articu- 
lation, noticed by surgical writers, which permits an undue movement of the 
* American Journal of the Medical Sciences, April, 1863. DISLOCATIONS OF THE ASTRAGALUS. 
121 
extremity of the bone. As this condition is usually associated with a feeble 
state of the general system, it will be proper to administer tonics; and, with 
a view to condense the fibrous connection of the two bones, the fibula should 
be forcibly rubbed against the tibia, so as to excite some inflammatory action. 
When the disability from the displacement is marked, the limb should be 
flexed and put at rest for some time. 
Dislocation of the Lower Extremity.-The only example of this luxation 
is one recorded by Nelaton, in which the lower extremity of the fibula was 
forced backward from its connection with the tibia, leaving the external 
malleolar surface of the astragalus easily distinguishable. The lower end of 
the fibula lay along the outer border of the tendo Achillis. The displacement 
was caused by direct force, and no effort was made to restore it. 
In a case of this kind, the foot should be extended, in order to relax the 
tendons of the peroneus longus and peroneus brevis muscles, and the external 
malleolus should be pressed directly forward. 
DISLOCATIONS OF THE TARSUS. 
The dislocations occurring in the bones of the tarsus are the following: 
first, dislocations of the astragalus; second, subastragaloid, or astragalo-calcaneo- 
scaphoid dislocations; third, dislocations of the os calcaneum; fourth, dislocations 
of the scaphoid; fifth, dislocations of the cuboid; and sixth, dislocations of the 
cuneiform bone. 
Dislocations of the Astragalus. 
These may be partial or complete, simple or compound. The bone may be 
displaced forward, backward, or laterally; there is also a displacement in 
which the bone is twisted or rotated on its axis. 
When the astragalus is completely disengaged from its connection with the 
tibia, the calcaneum, and the scaphoid, it may be impelled forward from its 
bed with such force as to rupture the soft parts and pass completely through 
the opening. Norris* mentions a case of this kind which was admitted into 
the Pennsylvania Hospital, and which resulted fatally from tetanus five days 
after receiving the injury. 
Luxation Forward.-This may be complete or incomplete. 
When complete, the astragalus is disjoined from the calcaneum and the 
scaphoid bones, and also removed from the mortise between the tibia and the 
fibula, taking a position in front of the scaphoid, or even still more forward 
on the cuneiform bone. This displacement may also be accompanied by a 
fracture of one or both of the malleoli. 
When the dislocation is incomplete, the degree of displacement will vary in 
different cases. It may consist in a separation of the head of the bone from 
the cavity of the scaphoid and its lodgment upon the latter. Or its connec- 
tion with the os calcis may also be disturbed, so as to admit of a still greater 
advance in an anterior direction, yet not sufficient to remove the bone entirely 
either from the intermalleolar arch or from the calcaneum. 
In consequence of these differences in the degree of displacement there is 
always a want of uniformity in the phenomena presented by forward luxation 
of the astragalus. 
The sign which most conspicuously signalizes the accident is the presence 
of an unusual and irregularly-shaped prominence in front of the ankle, be- 
neath the skin. As it is almost impossible for the astragalus to be projected 
directly forward, in consequence of its irregularity of form and the different 
checks to which it is subjected by its associate bones, it will in most in- 
stances be found turned towards either the inner or the outer side of the 
foot, deviations which will necessarily modify the resulting appearances. 
* Contributions to Practical Surgery, p. 155. 122 
DISLOCA TIONS. 
When rotated in an external direction, in addition to the projection formed 
by the astragalus in front of the ankle, and which is particularly prominent, 
the foot is turned inward; the external malleolus is unusually salient, and 
over the inner border and the sole the skin is wrinkled. (Figs. 1008, 1009,) 
Fig. 1008. 
Fig. 1009. 
Dislocation of the astragalus forward and outward. 
A, internal malleolus; B, head of the astragalus. 
When the bone is dislocated with an inward inclination or twist, the foot 
is turned outward, and the internal malleolus becomes markedly prominent. 
In an old, unreduced luxation of this variety of dislocation, dissected by 
Professor John Neill, the astragalus was found fractured near its posterior 
border, and the fragments separated by the tibia, which was wedged in the 
chasm between. 
Treatment.-The knee being flexed, so as to avoid the resistance of the 
gastrocnemius and soleus muscles, extension should be made from the foot 
and counter-extension from the leg below the knee, the surgeon at the same 
time pressing the astragalus backward into its proper position. 
If the reduction cannot be thus accomplished, and there is reason to be- 
lieve that the obstacle to success resides in the muscles of the calf, a sub- 
cutaneous division of the tendo Achillis should be made. Or, if the resistance 
can be traced to any other muscle of the leg, the division of its tendon will be 
indicated. Until these measures have failed, no case ought to be abandoned 
as incapable of reduction. 
Rest in a fracture-box, with lotions of cold water or laudanum and water, 
will constitute the after-treatment. 
Dislocation Backward.-In this displacement, the astragalus escapes poste- 
riorly from the intermalleolar space, and from the os calcis and the scaphoid 
bone, and is lodged on the upper surface of the posterior part of the os cal- 
caneum, between the tendo Achillis and the tibia. It may be twisted slightly 
inward, though generally the direction of the bone is directly backward. 
This dislocation is produced by force acting upon the anterior part of the 
ankle, when the tarsus is strongly flexed on the bones of the leg. It is not 
a common luxation, there being not more than eight or nine recorded cases. 
The signs of the dislocation are the presence of a hard, incompressible 
body above the heel, filling up the space between the tendo Achillis and the 
tibia, with shortening of the foot, in consequence of the tibia having been 
thrust somewhat forward. 
Treatment.-Of the eight recorded cases of this dislocation, only one- 
admitted to the University Hospital, London-has been reduced. In the 
single successful case, besides the luxation, there was a fracture of the tibia 
and fibula,-a circumstance which probably made this exceptional. 
Unpromising, however, as have been the attempts to reduce this dislocation, SUBASTRAGALOID DISLOCATION. 
123 
the surgeon must not be deterred by antecedent failures, but should try 
every safe measure to effect the reposition. 
The knee being flexed, so as to relax the gastrocnemius and soleus muscles, 
extension and counter-extension should be made, as in the anterior or forward 
displacement. At the same time, strong pressure should be applied on the 
bone, so as to compel it, if possible, to re-enter the intermalleolar space. 
If these measures do not succeed, the tendo Achillis should be divided, and 
the efforts to replace the bone should be renewed. In the event of ultimate 
failure, it does not follow that the luxation remaining unreduced will render 
the limb useless. On the contrary, in the cases noted by Phillips, Liston, 
Lizars, and Hamilton, a very excellent use of the limb was recovered. 
When it is found impossible to reduce the astragalus, the bone should be 
allowed to remain undisturbed, whatever may be its position. The surround- 
ing parts may become tolerant of its presence, and after a time the functions 
of the foot may be in a great measure regained. 
Excision should be resorted to only when the soft parts ulcerate and the 
bone becomes exposed. 
When the dislocation is compound (Fig. 1010), it will be better to extract the 
bone at once. 
Irreducible Dislocations of the Astragalus. 
Subastragaloid Dislocation, so termed by Malgaigne, is a separation of the 
calcaneum and the scaphoid bone from the astragalus. It has also been de- 
scribed as astragalo-calcaneo-scaphoid dislocation. (Fig. 1011.) 
In this luxation the astragalus still retains its position in the mortise be- 
tween the tibia and the fibula. It would seem almost impossible, when con- 
sidering the position of these bones, the disposition of their articulating 
surfaces, and the strength and number of their ligaments, that such a dis- 
location could occur short of a complete 
disorganization of the foot. And, indeed, 
such was the general belief of the pro- 
fession, until examples of the injury were 
published by Pollock, Adams, Macdon- 
nell, Detmold, and others.* 
Fig. 1010. 
Fig. 1011. 
Compound dislocation of the astragalus. 
Subastragaloid luxation. 
The displacement may occur in four different directions,-outward, inward, 
forward, and backward. 
This luxation may be distinguished from that of the astragalus by the fact 
* Medico-Chirurgical Transactions, vol. xlii. 124 
DISLOCATIONS. 
that in the subastragaloid dislocation the astragalus remains in its proper 
functional position,-which can be ascertained by noticing the distance be- 
tween the head of the astragalus and the malleoli. 
In the outward subastragaloid luxation the foot is inverted; in the inner 
form of the luxation the foot is everted; and in both forms the astragalus 
may be outlined in front of the ankle. 
Of the two remaining varieties of the dislocation, viz., the backward and 
the forward, the lattei' is the more common. 
The backward dislocation will be indicated by a shortening of the anterior 
part of the foot and by an unusual thickness of its medio-tarsal portion. 
When the luxation is forward, the anterior part of the foot is lengthened. 
Treatment.-When the displacement is not extreme, and there has been 
no serious laceration of the soft parts, an effort should be made to save the 
foot. In order to effect reduction, the leg must be sufficiently bent to insure 
the relaxation of the muscles of the calf of the leg. This will be necessary 
whatever may be the direction in which the displacement has occurred. If, 
now, the bones cannot be pressed by manipulation into place, the tendon of 
the gastrocnemius muscle must be divided, and another attempt made to 
accomplish the reposition. 
When the dislocation is outward, the tendons of the tibialis anticus and 
tibialis posticus are dragged tightly, the former ovei' the neck of the astrag- 
alus, and the latter against the groove of the tibia; and they may demand 
tenotomy. 
When all attempts to reduce the foot have proved unsuccessful, an expectant 
plan of treatment must be pursued. Should serious symptoms ensue, the only 
alternative is to remove the astragalus, or to amputate a portion of the foot. 
When the subastragaloid dislocation is compound, a Pirogoff or a Syme 
amputation should be executed without delay. 
Unusual Dislocations of the Astragalus.-In rare instances, the astragalus 
has been known to perform certain very singular freaks. It may be dis- 
placed directly upward (Fig. 1006). It may revolve on its axis in such a 
manner as to lie directly across the foot. It has been known to make the 
same semi-revolution on its vertical axis, and, at the same time, not to escape 
from the intermalleolar space. In other instances the bone has turned en- 
tirely around, its head presenting to the back of the leg and its posterior 
surface looking towards the scaphoid bone. Lastly, it has been turned 
over, in such a manner that its lateral surfaces had become vertical in their 
position, one resting on the under surface of the tibia and the other on the 
calcaneum. 
A few examples of this dislocation have been recorded. In most of these 
the luxation has been outward, separating the calcaneum from the astragalus 
above and from the cuboid bone in front. 
The characteristic symptoms resulting from the displacement are a distor- 
tion of the heel, a projection beneath the outer malleolus, and an inability to 
abduct or adduct the foot. 
The accident may be caused by a fall upon the heel, or by intense pressure 
applied to the side of the foot. 
Treatment.-When the luxation is easily recognized, its reduction appears 
to be attended with no unusual difficulty. In the two cases recorded by 
Malgaigne, displacement was easily corrected by M. Jourdan, by pressing the 
calcaneum inward, while an assistant at the same time pulled the leg outward. 
A similar success followed in the two cases of Mr. South.* His method 
of reduction, however, was a little different from that of Jourdan. 
In Mr. South's case the leg was flexed upon the thigh, thus relaxing the 
gastrocnemius, after which extension was made on the foot, by grasping with 
Dislocations of the Os Calcis. 
* Chelius's Surgery, by South, vol. ii. p. 354. DISLOCATIONS OF THE METATARSUS. 
125 
the two hands the heel and the instep, while strong pressure was exerted on 
the outside of the bone. 
Five cases of this luxation have been collected by surgical writers. They 
are as follows: one by Burnet,* one by Piedagnel,f one by Walker,| one by 
R. W. Smith,§ and one by Bryant,||-one of Mr. Birkett's cases. 
When the displacement is complete, the bone is separated from both the 
head of the astragalus and the three cuneiform pieces; and it will be recog- 
nized by the locality of the prominence. 
The prevailing direction of the luxations, I find upon analyzing the five 
recorded cases, is inward. Four were in this direction, and one upward. 
The manipulation required for the reduction of the dislocated scaphoid bone 
consists in making traction on the metatarsus, and at the same time pressing 
the bone in a direction opposite to that of the displacement. 
Dislocations of the Scaphoid Bone. 
Dislocation of the Cuboid Bone, as an independent injury, has not been 
clearly made out. South mentions a case of partial luxation of this bone, 
but it was accompanied by a similar luxation of the scaphoid. And, although 
Piedagnel speaks of dislocation of the cuboid bone in three directions,-up- 
ward, inward, and downward,-the statement is not supported by any ex- 
ample of the injury. 
The existence, however, of such a luxation, should it be encountered, would 
not, from the position occupied by the bone, be difficult to recognize. 
Dislocation of the Cuneiform Bones.-These bones may be dislocated sepa- 
rately or all together. The internal cuneiform is the one most liable to 
luxation. Sir Astley Cooper witnessed this accident in two instances. Dr. 
Velder, of Elmira, New York, has published a case of this luxation. The 
deformity which was said to follow consisted in a large prominence situated 
at the inner border of the foot, and somewhat above the level of the other 
bones. The fact that the apex of the internal cuneiform bone is above the 
other cuneiform, and has the tendon of the tibialis anticus attached to its 
inner side, will explain the direction of the displacement. Mr. Luke, of 
London, reported a case of incomplete dislocation upward of all three of the 
cuneiform bones; and Mr. one in which the two outer cuneiforms were 
in part luxated. 
To reduce this dislocation, the metatarsal bones must be carried strongly 
outward, while the ankle is fixed, so as to increase the space between the 
scaphoid and the metatarsal bone of the great toe. After this is done, the 
displaced bone should be pressed into its place. 
DISLOCATIONS OF THE METATARSUS. 
Notwithstanding the secure manner in which the metatarsal bones are 
interlocked and ligated to the tarsus, they are nevertheless occasionally dis- 
located. They may be luxated singly or together. 
The displacement can occur in four directions,-upward, doionward, and 
laterally {outward or inward}. The first is the most common form it assumes. 
Dr. Hitsig** has analyzed 29 cases of different metatarsal luxations, 16 of 
which were dislocations of the entire metatarsus, and 13 of single bones. 
Of the 16 examples in which the whole metatarsus was luxated, 11 were 
displaced in the upward direction. 
Dr. R. W. Smith has shown that in cases in which a single metatarsal bone, 
especially that of the great toe, is dislocated, it is often accompanied by the 
* London Medical Gazette, vol. xix., November, 1836. 
J Dublin Hospital Gazette, 1855, vol. ii. p. 76. 
|| Bryant's Surgery, p. 744. 
** New Sydenham Society's Biennial Retrospect, 1865-66. 
f Malgaigne, tome ii. p. 1037. 
Medical Examiner, 1851, p. 203. 
Guy's Hospital Reports, vol. i., 1836. 126 
DISLOCATIONS. 
tarsal bone with which it is articulated. Thus, in luxation of the first meta- 
tarsal bone, the internal cuneiform accompanies it, and is thrust upon the 
dorsal surface of the scaphoid. 
These dislocations are produced either by falls, in which the person lights 
upon the feet, causing the bones to be driven upward, or by heavy weights 
striking upon the dorsum or upon the sides of the foot. They are frequently 
caused by a pinch of the foot when caught between the wheel of a street- 
car and the flange on the iron rail over which it runs. In one case pro- 
duced in this way, the tarsal extremity of the first metatarsal bone was 
driven directly into the centre of the internal cuneiform bone. 
Symptoms.-The symptoms indicating luxation of the metatarsus are 
generally quite characteristic. When dislocation of one or more bones of 
the metatarsus occurs, shortening of the corresponding toe or toes follows, 
and the prominences of the latter can be seen and felt. When the entire 
metatarsus is luxated, the whole foot is foreshortened. In all of these luxa- 
tions the ankle and heel retain their natural form. 
Treatment.-The reduction is effected by making traction from the toe 
or toes answering to the displacement, by means of the fingers or through 
the medium of a noose, while at the same time the dislocated extremities are 
pressed in the proper direction. The best-applied efforts will sometimes fail 
of accomplishing the reposition. In this event, the surgeon's attention should 
be directed to the control of the inflammatory action which ensues upon the 
injury. A number of examples have been published in which, though re- 
duction was found impracticable, the patients recovered with useful feet. 
When, in addition to the luxation, there are extensive lacerations of 
the soft parts and comminution of the displaced bone, excision will be 
imperative. And when several of the metatarsal pieces are dislocated and 
crushed, amputation through a sound part of the foot will be required. 
DISLOCATIONS OF THE TOES. 
Dislocations of the phalanges of the toes are much more rare than similar 
injuries of the fingers. The great toe is the subject of luxation oftener 
than the others. The proximal phalanges are those generally dislocated. 
The displacement, though generally upward, may take place downward, or 
downward and inward. Sir Astley Cooper witnessed a case in which all the 
toes, except the great toe, were dislocated from the metatarsal bones; M. 
Josse has recorded a case of luxation of all the metatarso-pbalangeal joints. 
Dislocations of the toes are occasioned by blows, twists, extreme flexion, 
and force applied at the extremity of the last phalanges. 
The symptoms indicating this injury are shortening of the toe, and the 
existence of a prominence, formed by the articular extremity of the displaced 
phalanx. These luxations are frequently compound. 
The reduction is secured by extension, conjoined with properly-directed 
pressure. Flexion, perhaps extension, may also be demanded before the 
restoration is completed. 
When the great toe has been dislocated, the same difficulties may be en- 
countered as in luxations of the thumb. In four out of ten cases noted by 
Malgaigne, the reduction could not be accomplished. 
Should extension and counter-extension fail to drag the phalanx into place, 
the surgeon may adopt the method of extreme extension of the toe or its 
metatarsal bone, with pressure against its dorsal surface. 
In all dislocations of the metatarsal and phalangeal bones, after reduction, 
the parts, being enveloped in a cold anodyne lotion, should be supported in a 
fracture-box. If there exists a tendency to reluxation, it may become neces- 
sary to apply a plantar splint, cut and padded so as to conform to the shape 
of the foot, to which it must be secured by a roller. A plaster roller may be 
used for the same purpose. 
Compound dislocations of the toes necessitate excision or amputation. CHAPTER XII. 
DISEASES OF THE JOINTS. 
Movable Bodies within the Joints. 
Within the cavity of an articulation are occasionally found hard, mova- 
ble bodies, which not only interfere with the movements of the joint, but 
sometimes cause acute pain and excite inflammation of the synovial mem- 
brane. 
These bodies were first observed by Ambrose Pare, in the year 1558. He 
noticed a white, solid mass escape from a knee-joint which he had opened for 
the purpose of removing therefrom a collection of fluid. The subject seems 
to have attracted but little attention, as we hear nothing of these bodies 
again until 1691, when Pechlin describes a case of a similar kind. 
The articulations in which these formations are found are the elbow, wrist, 
temporo-maxillary, and knee. They occur most frequently in the latter. 
These movable bodies are of two kinds: first, those which appear as small, 
round, or flat concretions, and which consist of fibrin ; second, those which 
are irregularly round, often nodulated, and formed of ossifying cartilage. 
They vary in number, in size, and in color, There may be a single one in a 
joint, or many. Malgaigne met with as many as sixty in the elbow-joint; 
and Dr. Berry, of Kentucky, extracted thirty-eight from the knee of a negro 
man. Their size varies from that of a millet-seed to that of a pullet's egg. 
Their color is sometimes white or whitish-gray; at other times they are of 
a faint yellow tint. They may be completely isolated from all surrounding 
connections, or be moored by a filament of fibrin to some point of the syno- 
vial membrane. (Fig- 1013.) 
Those belonging to the first or fibrinous variety originate in different ways. 
They may be formed out of the flakes or masses of fibrin which float in the 
transudation attending a synovitis; they may arise in the synovial fluid 
which has been changed in its constitution by inflammation; or they may 
form,-by condensation of fibrin, around a mass of coagulated blood which 
has found its way into a joint by the rupture of a vessel. (Fig. 1012.) 
Those of the second variety are organized bodies, and are derived from 
four distinct sources, the first being the synovial fringes. In the apices of 
these, cartilage-cells are sometimes known to exist, which, under the stimulus 
of inflammation, undergo active proliferation, thus forming a cartilaginous 
nodule, which ossifies in the centre. This is subsequently detached by the 
movements of the joint, and falls loose or free into its cavity. Secondly, one 
or more of the apices of a synovial tuft may become pinched between, or 
crowded against, the contiguous surfaces of the bone, giving rise to a local- 
ized inflammatory infiltration and thickening, which may subsequently be 
crushed off from its connection with the synovial membrane and drop into 
the joint. Thirdly, these bodies may arise outside of the synovial mem- 
brane in the periosteum, or in the subsynovial connective tissue, as osteo- 
phytes, and be forced into the joint. And fourthly, they may, as Mr. Teale 
has suggested, be the result of fragmentary exfoliations of the cartilages of 
the joint. Dr. Adams, of Dublin, believes that they may also have an osteo- 
arthritic origin. 
The presence of one of these movable bodies in a joint is sometimes first 
recognized after a synovitis followed by hydrarthrosis. In other instances, 
127 128 
DISEASES OF THE JOINTS. 
nothing which accounts for the existence of the formation can be learned 
from the history of the articulation. 
Symptoms.-The patient, while walking, or in some movement, is suddenly- 
seized with a severe pain, and is unable to move the joint. He becomes 
sick and faint, and sometimes 
is compelled to grasp the near- 
est object to keep himself from 
falling. In a few moments, if 
the posture of the limb is 
changed, the body slips from 
the articulating end of the 
bone, the pain instantaneously 
ceases, and the function of the 
articulation is immediately re- 
stored. At other times, the 
joint may become locked with- 
out involving any acute suffer- 
Fig. 1013. 
Fig. 1012. 
Fibrinous concretions found in a joint. 
Numerous movable bodies in the elbow-joint; some attached by 
fine pedicles.-Cruveilhier. 
ing,-a circumstance, doubtless, depending on the position of the movable 
body. 
The inconvenience resulting from the presence of these movable bodies 
will be determined by their mobility, whether entirely detached from the 
surrounding parts, or restrained by a pedicle. In the latter case the patient 
may enjoy a long exemption from an articular lock, and then have several 
attacks in quick succession. It is not improbable that during the quiescent 
period the cartilage has been either glued by a little inflammatory lymph 
to some part of the joint, or has fallen into some little recess, formed by the 
folds of the synovial membrane, by which it has been temporarily fixed; and 
the return of the symptoms denotive of its presence indicates that it has 
again been detached or dislodged. 
In most cases the new formation can be felt under the quadriceps muscle, 
on one side of the tendon of the patella, or at the inner side of the joint; 
and it may even be pushed about by the surgeon's fingers. These indications, 
taken in connection with the suddenness of the attacks and the severity of 
the pain, will suffice to establish the true nature of the affection. 
In that variety of the disease in which these formations arise from the 
synovial fluid, or from its intermixture with lymph, the symptoms are by 
no means so pronounced as when they have an osteo-cartilaginous structure. 
The only evidence of their existence will be the presence of a moist friction- 
sound when the patella is pressed upon the condyles, or when the joint is 
flexed and extended. But, as the same symptom is frequently present in MOVABLE BODIES WITHIN THE JOINTS. 
129 
chronic synovitis, and when no such bodies exist, their recognition is attended 
with great uncertainty. 
Treatment.-As long as the patient is capable of moving about without 
suffering more than an occasional attack, it is best not to interfere, or, at 
most, not to attempt anything more than palliation. The body has sometimes 
been directed into a retired part of the joint, where it occasioned no pain, and 
then fixed by a compress and adhesive straps. This was the plan proposed 
by Gooch. Mr. Hilton, in addition to thus fixing the cartilage, afterwards 
locks the knee by a splint, so as to compel the patient to walk with a stiff 
joint. In some cases, a laced knee-cap will prevent the occurrence of an 
attack. Nothing answers a better purpose than to apply a plaster roller to 
the articulation, which, in the case of the knee, while it does not prevent 
walking, limits the motion of the joint. The inflammation which follows an 
attack must be treated as an ordinary synovitis,-that is, by rest and anti- 
phlogistics. 
Cases, however, will occur in which, from the constant disability of the 
joint, and oft-recurring inflammatory attacks, it becomes necessary to extract 
these bodies. 
Two operations have been practiced for this purpose,-by direct incision, 
and by indirect or subcutaneous incision. The latter, when possible, should 
always be preferred, as the less dangerous. 
When an operation is contemplated, if the patient is suffering from any 
irritation of the joint, he should be confined to bed for several days; the limb 
should be kept at rest, and local antiphlogistic remedies applied to the artic- 
ulation until all signs of inflammatory disturbance have disappeared. If the 
method by direct incision is selected,-that practiced by Abernethy, Desault, 
Chelius, and others,-the foreign body must be slid, either by the guidance 
of the patient or by the fingers of the surgeon, into a favorable situation on 
one side of the joint,-e. g., in the case of the knee, along the inner side of the 
patella. The operator then, sliding the superincumbent skin to one side, cuts 
directly down upon the body, and presses it out through the incision, imme- 
diately releasing the integument, which, returning to its former situation, 
destroys the correspondence between the superficial and the deep portions of 
the incision. A compress, moistened with carbolized oil, should be next 
laid over and bound upon the wound, and the joint immovably fixed in a 
plaster or other splint. When it is feasible, the operation should be performed 
under the carbolic acid spray, and dressed antiseptically. 
By the plan of subcutaneous incision,-that devised by Syme and, about 
the same time, by Goyrand,-there is less danger of air entering the joint. 
The foreign body must be forced into the most superficial and accessible part 
of the joint, which is one on the head of the tibia and to the inner side of the 
tendo patellae. It may then be fixed, either by the finger, or by a strong needle 
mounted on a handle and thrust into its substance. The surgeon now in- 
troduces a tenotome-knife through the tissues, one-half or three-quarters of an 
inch below, and carries it obliquely upward until the cartilage is reached, when 
the blade of the instrument is made to divide freely the surrounding parts. 
After this, the body must be pressed through the opening into the cellular 
tissue exterior to the joint, where it may be allowed to remain, or may sub- 
sequently be extracted after all risks of inflammation have passed over. In 
this way, with the greatest ease and without subsequent untoward symptoms, 
I have removed quite a large cartilage from the knee-joint. The same care 
in dressing the wound, and the same precautionary measures of rest and 
cold applications, employed in the former method of treatment, must be 
observed. When the body is very irregular on its surface, however, this plan 
will often fail. 
When a number of these bodies exist in a joint, it will be better not to 
attempt too much at a single operation, but to repeat the extractions at con- 
siderable intervals of time. 
The statistics which have been collected on this subject demonstrate the 
VOL. II.-9 130 
DISEASES OF THE JOINTS. 
subcutaneous to be the safer of the two methods. For example, of the 216 cases 
collected by Dr. Benndorf, of Leipsic, in which these bodies were removed 
by direct incision, 143 recovered without complications, 41 perished, and 32 
suffered from severe and dangerous symptoms. In 50 cases operated on by 
the subcutaneous plan, 28 were cured, 5 died, 5 suffered from severe symp- 
toms, and in 12 the operation was abandoned without being completed. Mr. 
W. I. Square, of Plymouth, reported to the British Medical Association, in 
1871, 24 successful operations by the subcutaneous method. The statistics 
published by II. Larrey* embody 167 cases, of which 129 were operated 
upon by the direct incision. Of this last number, 96 were cured, 28 died, 
and 5 operations failed; while of the 38 cases treated subcutaneously, 19 
were cured, 5 died, and 14 failed. 
Anatomical Summary of the Components of a Joint.-A joint is composed 
of the ends of two bones, each covered by a layer of cartilage; and, in ad- 
dition, in certain joints, such as the knee or the lower jaw, there are between 
the bones plates of cartilage, called inter articular cartilages. The cavity of a 
joint is lined by a serous membrane (the synovia/), which penetrates into all the 
recesses of the articulation, forming diverticula, or pouches. In order to amplify 
the extent of the secreting surface of this membrane, it is also, at certain points, 
thrown into folds and fringes. The articulation is bound together by strong, 
inelastic fibrous bands and sacs, called ligaments. This mechanism is supplied 
with blood-vessels and nerves, and is moved by muscles whose tendons are 
distributed about the articulation, in many instances confined to their places 
by tubular sheaths or playing over burs® possessing membranes that secrete 
a fluid resembling in many respects the synovial fluid. The same nerves 
w'hich supply the muscles contiguous to a joint furnish branches also to the 
latter. There are, therefore, comprehended in the idea of a joint, osseous, 
cartilaginous, serous, and fibrous tissues; and in its pathological changes the 
part played by the muscles is often such that, in the management of a case 
of articular disease, they cannot be ignored. 
Notwithstanding the articulations are composed of parts apparently so 
dissimilar, they possess an anatomical unity both in structure and in con- 
tinuity of parts, the basis of their components being connective tissue. It 
is, consequently, very difficult to divorce pathologically those which ana- 
tomically are one. The influence of this organization upon the morbid phe- 
nomena attending disease doubtless had much to do in originating the loose 
classification adopted by the older surgeons, who were wont to treat all af- 
fections of the articulations under the general head of arthritis. For the cor- 
rection of this error, and for a more rational arrangement of joint diseases, 
we are chiefly indebted to Sir Benjamin Brodie, who, by careful dissections, 
succeeded in reducing to order what had previously been a subject of con- 
fusion and uncertainty. While it is true that a classification based on ana- 
tomical peculiarities of structure is usually a sound one, it is possible that 
even this may be carried to a degree of refinement, as, I think, has been 
done by our French brethren, calculated to encumber the subject with need- 
less discussions, destitute of both scientific and clinical value. 
I shall make two general divisions of articular affections,-traumatic and 
idiopathic. Under the first, or traumatic division, are included sprains, con- 
tusions or concussions, and wounds. The second, or idiopathic division, em- 
braces all those diseases which arise from causes resident in the general 
system, such as rheumatism, gout, syphilis, gonorrhoea, struma, pyaemia, etc. 
TRAUMATIC ARTICULAR DISEASES. 
Sprains and Contusions, though somewhat different kinds of injuries, as 
they are followed by similar effects, and as they demand the same mode 
of treatment, may very properly be considered under one bead. 
* Gazette des Hopitaux, No. 67,-Bryant. TRAUMATIC ARTICULAR DISEASES. 
131 
Sprains.-A sprain is the violent wrenching or twisting of a joint, occa- 
sioned by a fall or a blow, in which some of the ligamentous fibres of the 
articulation are over strained or torn, and the blood-vessels of the synovial 
membrane, and, in severe cases, the membrane itself, ruptured. In addi- 
tion to these lesions, the tendons and their sheaths on the periphery of the 
articulation are frequently involved in the injury. These accidents are very 
common, and often, when improperly managed, lay the foundation for serious 
articular disease. 
The joints which suffer most from sprains are the ginglymoid, such, for 
example, as the ankle, knee, and wrist. In articulations of this class, whose 
movements are chiefly those of flexion and extension, there is no provision 
for lateral movements to any extent, and consequently, when an ankle or 
a knee is violently abducted, adducted, or twisted, the force is concentrated 
on the lateral ligaments, causing them to give way to a greater or less extent. 
In the ball-and-socket joints, motion is free in all directions, and the lesions 
of a sprain cannot occur, except when the movements are carried to an 
extreme degree. 
Contusion or Concussion.-In contusion, the force acts in a manner dif- 
ferent from that in a sprain. It is transmitted through the joint, much in 
the same way as the momentum of a missile, after striking upon the skull, 
is communicated to the brain or its membranes. The force may act directly, 
as when a blow is delivered over the surface of a joint, or indirectly, as when 
the knee-joint is contused by a fall from a height upon the feet. Sometimes 
one of the elements of a sprain, that of ligamentous tension or rupture, may 
be conjoined to the concussion, as when the wrist-joint is injured by a blow 
with the clenched fist. Here, in addition to the direct transmission of force 
to the joint, the latter is flexed or extended. In severe concussion, besides 
contusion of the soft parts and of the vessels exterior to the joint, there is 
laceration of the vessels of the synovial membranes, and frequently of the 
membrane itself. 
In both sprain and concussion, the essence of the disease consists in an 
excessive hypenemia of the subserous vessels, followed by traumatic arthritis, 
which, beginning in the synovial membrane, may extend to the other com- 
ponents of the joint. 
Symptoms.-Immediately succeeding a twist or other injury of a joint, 
there is experienced a severe, sickening pain. If the injury is serious, the 
articulation is at once rendered helpless, and in a few minutes becomes 
swollen. A throbbing sensation is experienced in the part, attended by an 
increase of temperature and severe suffering upon the slightest motion. As 
the swelling increases, a change takes place in the position of the limb. If 
the knee or the elbow has suffered, the limb becomes flexed ; if the ankle, 
the foot drops; if the wrist, the position assumed is one of flexion, with ad- 
duction. These changes of position are induced by the inflammatory trans- 
udation within the joint, and are those which permit of the greatest distention 
of the synovial sac, with the least amount of tension, as may be proved upon 
the cadaver by injecting fluid into any of the joints named. This flexion may 
also be produced by reflex muscular contraction, due to the intra-articular 
irritation, which is communicated to the flexor muscles of the joint, through 
the agency of the nerves. When the ligaments have been torn, even to a 
very moderate extent, it will be found that there is an undue lateral move- 
ment of the articulation. This can be readily ascertained by grasping the 
limb above the injured joint and holding it firmly with one hand, while with 
the other the part below is carried from side to side. 
Diagnosis.-The only injury likely to be confounded with sprain or con- 
tusion is dislocation. In the former, however, the normal relations of the 
bony prominences of the joint will be found unchanged, the length of the 
limb unaltered, and all the movements of the articulation preserved, being 
only restricted in consequence of the pain attending them. 
Treatment.-There are three indications to be fulfilled in the treatment 132 
DISEASES OF TEE JOINTS. 
of sprains and contusions. First, to control inflammation; second, to secure 
the absorption of the transudation ; third, to restore the function of the joint. 
The first, that of controlling inflammation, is most satisfactorily accom- 
plished by elevating the limb and surrounding the articulation with a 
wrapping of paper lint, light flannel, or old linen, previously saturated with 
a cold mixture of laudanum and water,-expedients employed to take ad- 
vantage of the therapeutic power of gravitation, cold, and local anaesthesia 
over the force of the blood-stream. 
Frequently, hot applications are preferable to cold. The sensations of the 
patient must determine the choice between the two; and if the tension and 
throbbing of the joint do not soon begin to subside after the employment of 
the cold applications, these must be immediately exchanged for the warm. 
In severe sprains I have generally found the warm applications to yield the 
greatest comfort. A thick piece of flannel or paper lint, well soaked in hot 
water to which a little laudanum has been added, should be placed around 
the injured articulation, and, to preserve the heat and moisture, it should be 
covered with oiled silk or a rubber cloth. 
Decoctions of chamomile or of hops may also be used in the same manner. 
The effect of the warmth and moisture is to favor transudation, and also to 
mollify and soften the tissues, thereby unloading the engorged vessels and 
taking off the pressure from the nerves. These applications must be renewed 
four or five times during the day. 
Twenty-four or thirty-six hours will usually suffice, under the above meas- 
ures, for the culmination of the acute stage of the congestive or inflamma- 
tory factor of the sprain. After this, it becomes necessary to attend to the 
removal of the transudation which causes the swelling. 
To accomplish this end, the hot applications may be laid aside, and slightly 
stimulating or astringent applications, conjoined with pressure, substituted. 
A piece of old linen or gauze flannel, after being moistened with soap lini- 
ment, dilute alcohol, tincture of arnica, or a solution of common salt in vine- 
gar, should be laid over the joint, and covered in with the turns of a roller 
applied with sufficient firmness, but so as to cause no pain or uneasiness. At 
every renewal of the dressing the bandage must be drawn tighter, so as to 
keep pace with the receding swelling. 
During the entire course of the treatment the most perfect rest of the 
joint and the position most comfortable to the patient must be insisted upon. 
This cannot be too strongly enforced. 
The third and last indication is to restore the functions of the articulation. 
After a severe sprain or contusion there often remains, after the subsidence 
of the inflammation, a certain thickening or plastic infiltration of the con- 
nective tissue of the synovial membrane; and not unfrequently this extends 
also into the surrounding ligaments and sheaths of the tendons, causing 
rigidity and stiffness of the articulation. This infiltration, in its early his- 
tory, is very imperfectly organized, and, consequently, can then be quickly 
removed. To effect its removal, motion is all-important. 
I have earnestly enjoined rest in the treatment of sprains and contusions. 
But rest has its limits. Invaluable at first, or during the acute stage of the 
injury, after this stage has passed over it becomes a great evil, and I do 
not hesitate to say that the usefulness of many joints is greatly impaired, 
and in some cases seriously damaged, by an injudicious persistence in a state 
of rest. Whenever the inflammatory stage is overpast (which may be de- 
termined by the diminution of swelling, sensibility, and heat), the time has 
arrived to commence motion of the joint. Even when there remain consid- 
erable swelling and some undue sensibility, if the thermometer reveals no 
abnormal elevation of temperature, this motion need not be delayed. The 
movements to be made are those peculiar to the joint, such as flexion, exten- 
sion, etc. They must be made by the surgeon or by an instructed attendant, 
at first very gently and only for a few seconds, two or three times a day, at 
every repetition increasing the manipulation both in energy and in duration. IRRITABLE JOINT. 
133 
If the joint-tissues do not resent these liberties by becoming hot and more 
swollen, the patient may be allowed to practice this exercise by his own 
muscles; and after a few days more he may begin to use the joint. If the 
sprain has been severe and involves the knee or ankle, he may call to his aid, 
for a short time, a pair of crutches. In order to impart tone to the structures 
about the joint and to contribute to its protection, the use of a cold-water 
douche and the application of a flannel band will be desirable. Where the 
means thus detailed are faithfully employed, it is astonishing how quickly a 
patient can be got upon his feet and be enabled to resume his usual occupation. 
Rarely will it be necessary to resort to leeches and purgatives to subdue the 
inflammation, as advised by many writers. When the ligaments have been 
extensively torn, it will be a long time before the strength and usefulness of 
the articulation are regained. While this circumstance does not militate 
against the employment of movements, it will be necessary to use great 
caution in the exercise of the limb, as well as to take advantage of artificial 
appliances to support in part the weight of the body. 
Cases will now and then come under the surgeon's observation in which 
badly-treated or neglected sprains and contusions, either from repeated at- 
tacks of acute or from chronic inflammation, occasion considerable structural 
alterations. The soft parts around the joint are swollen and indurated, and 
its movements are stiff, restrained, and painful. Sometimes the pain attending 
these injuries resembles rheumatism; and, being frequently aggravated by 
certain atmospheric changes, they doubtless do partake somewhat of the 
nature of this affection. 
These are cases which demand the combined operation of blisters, soaking 
in hot water, massage, well-appointed movements, pressure, and the appli- 
cation of the compound solution of iodine over the joint. 
Irritable Joint.-There is a peculiar form of joint-trouble which is one of 
the effects of sprain and of contusion, to which I have given the name of 
irritable joint. It manifests itself several weeks-more commonly several 
months-after an injury of one of the articulations, most generally that of 
the knee. The invasion is sudden and unexpected, sometimes occurring by 
an unaccountable giving way of the joint, at other times without any prece- 
dent warning of the kind, while the person is quietly walking on the street, 
or across the floor. In a few minutes the capsule of the joint is filled with 
fluid, and the limb becomes almost entirely helpless. Tenderness and even 
pain are experienced when pressure is made over the internal condyle, and the 
limb cannot be flexed to the full extent without causing muscular resistance 
and suffering. 
This affection, though most frequently met with in females, is not peculiar 
to them, but may occur in males also. The suddenness of the attack, the 
absence of any unusual heat, and the localized sensibility over that part of 
the articulation which is covered by the branches of the saphenous nerve, 
all point to a congestive rather than an inflammatory origin, induced most 
probably by some peculiar state of the articular nerves. 
The radical cure of these cases is often very difficult. Rest, blisters, com- 
pression, and moderate extension (effected either by a weight suspended from 
the leg, or by a cord of elastic tubing connected with the foot and fastened 
to the foot of the bed), together with the use of quinine, iron, and strychnia, 
constitute the proper remedies. In the course of two or three weeks they 
usually enable the patient to get about; but they do not so thoroughly eradi- 
cate the disease as to confer an immunity against other attacks. 
There is another form of irritable joint which demands some notice, and 
which is a sequence of sprain or of contusion. It may follow soon after re- 
covery from one or other of the above injuries, or it may not appear until 
several months have elapsed. The joint after being used becomes weary, 
hot, and somewhat sensitive to pressure. Extreme flexion is painful, and 
■when the joint-surfaces are strongly impelled against each other, a deep-seated 134 
DISEASES OF THE JOINTS. 
soreness is experienced. Little, if any, swelling is present. But the joint 
is considered so unreliable that it is with difficulty the patient can be induced 
to trust himself upon his feet. These symptoms all disappear after a few 
days of rest, recurring, however, upon the use of the limb. 
The treatment consists first in the immobilization of the joint, by means 
of a posterior splint formed of leather and stiffened with thin strips of 
steel; or a recurrent plaster roller may be used. The plaster splint, which 
is very easily constructed, answers the purpose admirably. It is formed as 
follows. First, apply a plain roller to the limb, commencing seven or eight 
inches below the knee, and terminating about the same distance above. Then, 
taking a plaster roller, after dipping it in water, carry it transversely back 
and forth over the first bandage, leaving one inch on the anterior face of the 
limb uncovered. These recurrents must be repeated until a sufficient number 
have been made to afford, when dry, the support necessary for the articula- 
tion ; and, to keep them in close contact with the parts, three or four strips 
of a narrow roller may be tied around the limb. When the splint hardens, 
it forms an accurate cast of the limb, and can be sprung open sufficiently to 
allow of its removal and readjustment without in any way impairing its 
value. 
After having provided for the fixation of the joint, it will be necessary to 
establish some form of permanent counter-irritation. Although I believe the 
value of the actual cautery is greatly over-estimated in its application to many 
affections, I am disposed to regard its use with favor in the treatment of 
the disease undei- consideration; not that any special virtue resides in the 
caloric, but simply because the resulting ulcer remains for a considerable 
time unhealed, and therefore prolongs the counter-irritation. Two or three 
linear cauterizations may, accordingly, be made with the hot iron over dif- 
ferent aspects of the joint. After the slough has dropped, the ulcers should 
be dressed with the compound resin ointment. 
For the first three or four weeks the patient must be confined to bed, after 
which crutches may be allowed. No attempts at passive movements of the 
articulation should be made earlier than at the expiration of two months; 
and on no account should the weight of the body be supported upon the 
affected side until the lapse of three months. When the patient begins to 
walk, it must be in a systematic manner, first taking a few steps, and every 
day gradually increasing the exercise by slow degrees, until the accustomed 
use of the limb has been regained. In this way we may hope to restore the 
permanent usefulness of the joint. 
Wounds of the Joints. 
When a wound has penetrated the cavity of a joint it constitutes a serious 
injury. The complications to be dreaded are both of a local and of a con- 
stitutional nature. 
We see here the great difference between subcutaneous, traumatic arthritis, 
and that which follows an external wound. In the first, there is little tend- 
ency to suppuration; in the latter, there is strong probability of such a 
result. Pus, when confined within the synovial sac, has no way of escape, 
and is apt to destroy the joint, while the acute symptoms which attend artic- 
ular suppuration soon give rise to fever and general constitutional disturbance. 
The gravity of all penetrating joint-wounds is not the same, though even 
in the smallest articulations the danger of anchylosis is imminent. It is 
when the large joints, such as the knee, the ankle, the elbow, and the wrist, 
are opened that the injury becomes hazardous to the limb, and even to the 
life of the patient. 
Symptoms.-The sign of a wound having penetrated a joint is the presence 
of a slightly reddish or colorless liquid, having a viscid, sticky, unctuous 
feel, and which, when rubbed, can be drawn out between the fingers into 
long threads. Should the puncture or cut have opened a bursa, a similar WOUNDS OF THE JOINTS. 
135 
discharge will appear,-a circumstance which might lead to an erroneous in- 
ference, by creating an impression that a joint has been opened, when such is 
not the case. When there are sufficient grounds to render the diagnosis un- 
certain on this point, and only then, a very fine silver probe may be carefully 
introduced into the wound. The depth to which the instrument extends will 
resolve all doubts. If the wound is extensive, the patient becomes weak, 
sick at the stomach, and pale. In those severe lacerations and comminutions 
of the joints which are produced by machinery and by balls, the most pro- 
found collapse is witnessed. 
The danger arising from all penetrating articular wounds is due to inflam- 
mation of the synovial membrane. All other pathological changes witnessed 
in extreme cases are dependent upon and secondary to this. These will be 
treated of under the bead of synovitis. 
Treatment.-The indications to be observed in the treatment of a wound 
of the joint are the arrest of hemorrhage, the removal of foreign matter, 
the approximation of the sides of the opening, and the prevention of undue 
inflammation. Except in military practice, it is not often that any serious 
bleeding is witnessed in this class of injuries. The vessels on the periphery 
of an articulation are usually small, and the bleeding ceases spontaneously. 
Should this not be the case, the vessels must be tied, the animal ligature being 
preferred for this purpose. After the parts are cleansed, they should be 
brought carefully and accurately together, either by sutures, adhesive plaster, 
or strips of silk gauze saturated with collodion. During the cleansing and 
approximation of the margins of the wound, the parts, when it is possible, 
should be kept under the antiseptic spray; and after the completion of this 
part of the dressing they should be covered with the carbolized gauze and 
mackintosh. Finally, the entire limb should be surrounded with a moder- 
ately firm roller. In the absence of antiseptic appliances, the wound may 
be covered with a piece of lint wet with carbolic acid and sweet oil. The 
crowning part of the dressing, however, without which all else is compara- 
tively valueless, consists in the absolute immobilization of the joint. This 
can be most perfectly accomplished in the case of the knee by applying 
plaster rollers from the foot to the upper third of the thigh, cutting a 
trap in the dressing over the wound, and then suspending the limb. By 
these provisions the dressings can be removed and replaced without any 
unnecessary handling or disturbance of the joint,-a matter of the first 
importance. 
The diet, for the first four or five days, must be restricted, and any feverish 
excitement which may arise should be combated by a saline laxative, followed 
by the neutral mixture, to which may be added a little morphia. If every- 
thing progresses favorably, in five oi* six days the sutures may be removed, 
though the limb must not be taken out of the splint for four or five weeks 
afterwards, at which time the patient may be considered well. 
It is not always, however, that a case progresses in so favorable a manner, 
particularly if there has been any delay or defect in the plan of treatment. 
It may happen that after the lapse of a few days the patient begins to 
complain of pain and uneasiness in the articulation, accompanied with some 
acceleration of the pulse and undue heat of the skin. If the dressing is 
opened, the joint will probably be found swollen and very sensitive to the 
touch, and possibly a little blood-stained synovia may be observed oozing 
through between the margins of the wound. 
These symptoms denote the presence of a traumatic synovitis; and although 
justly constituting a source of anxiety, this is susceptible of resolution. It 
is the signal for commencing a vigorous antiphlogistic treatment. For this 
purpose the local abstraction of blood by leeches and the application of ice- 
bags to the articulation will become necessary. The latter may be done 
■ without the removal of the splint, only requiring that portions ovex* the 
front and sides of the joint be cut out. If, after a fair trial, the cold fails to 
give relief, the ice-bags may be removed and the joint covered with a large 136 
DISEASES OF THE JOINTS. 
blister. The pain must be subdued by opiates, and these can be advantage- 
ously combined with a mercurial. Half a grain of calomel and the same 
amount of opium may be administered every houi' until relief is experi- 
enced, when they may be given at longer intervals. The calomel should be 
suspended upon the earliest manifestation of the gums becoming affected. 
In favorable cases, under these measures, the fever abates, the pain and 
swelling about the joint gradually subside, and the patient recovers. This is 
one termination; unfortunately, there may be another. The synovitis may 
not yield to the treatment; the pain and swelling grow rapidly wmrse, the 
temperature rises, the limb becomes oedematous, and the slightest movement 
of the joint is attended with the most intense suffering, so that the patient 
dreads the approach of an attendant towards the bed. Accompanying these 
symptoms will be evening exacerbation of fever, preceded by rigors, and 
followed frequently by exhausting sweats, an entire inability to take food, 
and the rapid loss of flesh. As the distention of the joint increases, the limb, 
unless secured to a proper splint, becomes more and more flexed,-a change 
of accommodation having both a mechanical and a physiological explanation, 
already given when treating of sprains. 
At this stage of the disease fluctuation may be detected, announcing the 
formation of pus. But even in this unfavorable aspect of the case there is 
still ground to hope for a cure. 
Whenever, then, fluctuation is discovered, and the synovial sac continues 
to enlarge, the joint should be aspirated and the fluid removed. This opera- 
tion must not be too long delayed: the presence of pus is very damaging to 
the joint; and if the synovial membrane once gives way, and. the purulent 
accumulation escapes into the surrounding tissues, the fate of the articula- 
tion, in all probability, will be sealed. 
After tapping the joint, or even when this is not done, the limb must be 
straightened, so that in the event of anchylosis taking place it shall be in 
that position which will render it most serviceable. The pain attending the 
correction of the flexion is so great that the use of an anaesthetic will be 
necessary. 
The purulent fluid having been removed, the subsequent management of 
the case will consist in painting the surface of the joint freely with the com- 
pound solution of iodine, applying pressure by means of a roller, and con- 
tinuing the use of the splint. After all signs of active disease have disap- 
peared, it will be proper to venture on making some passive motion, so that 
the use of the articulation may not be lost. 
In still more aggravated cases, the suppuration is not confined within the 
limits of the synovial sac. The latter either opens by ulceration or is rup- 
tured, allowing the purulent contents to escape into the tissues around ; 
abscesses form at numerous points in the vicinity of the joint; the liga- 
ments and cartilages participate in the inflammation, and the patient, under 
the exhausting effects of the suppuration, rapidly loses strength, and is liable 
to perish either from pysemia or from hectic irritation. In such cases, our 
only hope is anchylosis, excision, or amputation. 
To favor the first, the wound in the joint should be freely laid open, so as 
to furnish a ready exit to the discharges, and to render the cavity of the 
joint accessible to injections of nitrate of lead, of weak solutions of iodine, or 
of carbolic acid, with which it should be washed out twice every twenty- 
four hours. In the same mannei' the abscesses around the articulation must 
be opened, and a thorough drainage established, by the use of Chassaignac 
rubber tubes, or by wisps of oakum, so as to remove every source of irrita- 
tion or infection. The limb at the same time should be placed in a proper 
position on a splint which will admit of no motion, so as to encourage an- 
chylosis. 
During this time the general system of the patient must be sustained by- 
a generous diet and by the use of tonics and stimulants. 
If, notwithstanding every precaution, there is a steady emaciation, accom- SYNOVITIS. 
137 
panied with increasing hectic symptoms, it will be advisable not to depend 
longer on the power of the patient to resist the disease. Otherwise the 
opportune period for excision or amputation may be lost. 
Inflammation of the synovial membrane of a joint is a very common affec- 
tion, and arises from both local and constitutional causes. It may be either 
acute or chronic in its character. No articulation is exempt from the disease, 
though the large joints, as the knee, the elbow, the wrist, the hip, and the 
shoulder, suffer most frequently. 
Among the local causes may be mentioned wounds, sprains, contusions, 
cold, and foreign bodies within the joint. When induced by exposure to 
dampness and cold, the inflammation will usually be of a rheumatic nature. 
In a large proportion of cases, however, the disease will be found to owe its 
existence to constitutional causes, such as gout, struma, syphilis, pysemia; it 
is not unfrequently due to exanthematous affections. 
Sometimes synovitis is primary; at other times it may be secondary to dis- 
ease in another part of the joint, as in the bone or cartilage. It rarely exists 
for any great length of time without extending to the other components of 
the articulation. 
Like inflammation of serous membranes in other parts of the body, 
synovitis is followed by transudation, which may be serous, fibrinous, oi' 
purulent. There is, however, some difference between the inflammation of 
the synovial membrane and that of other membranes of this class. For ex- 
ample, a pleuritis or peritonitis of the mildest kind is generally followed by 
plastic adhesions, or by formation of pus; but such results, when following 
a synovitis, are usually evidences of long-continued chronic inflammation. 
Symptoms.-Synovitis is sometimes preceded by soreness and stiffness of 
the articulation, gradually ending in pain over a particular spot,-e.g., one or 
other of the condyles of the femur, when the knee is the subject of the in- 
flammation. This pain gradually extends until it is experienced throughout 
the entire articulation. In not a few instances the disease is announced 
without any precedent discomfort, the patient being suddenly attacked with 
acute suffering in the joint, any movement of which aggravates the distress. 
The skin may remain without discoloration, or may present a slight blush 
and the temperature be notably increased. The pain, after one or several 
days, is followed by swelling of the joint. On comparing the affected artic- 
ulation with its fellow, the characteristic depressions which belong to the 
normal joint are seen to be effaced. The distention of the synovial sac will 
be greatest in the direction of least resistance,-e.g., in front, under the quad- 
riceps muscle and the patella, when the knee is affected, and posteriorly, 
beneath the triceps, on each side of the olecranon, when the elbow is the 
seat of the disease. 
Fluctuation, which is one of the signs of synovitis, is modified materially 
by the nature of the fluid within the joint. When it consists chiefly of 
serum mixed with the synovia, which is the quality of the fluid in cases of 
uncomplicated synovitis, the fluctuation is very distinct; it becomes less so 
in proportion to the amount of fibrin present. 
In some cases, any movement of the limb is painful; in others, it can be 
flexed and extended without causing suffering. If the attack is more acute, 
as when arising from rheumatism, there may be, in addition to the local 
signs just enumerated, marked constitutional disturbance, as indicated by 
a full and frequent pulse, thirst, dry skin, and scanty, high-colored urine, 
loaded with urates. It is common in this condition of the disease to find 
the skin over the articulation discolored by a slight blush, tense and glossy, 
the limb flexed, and the patient complaining of a deep-seated pain, often 
worse in the evening, and accompanied by muscular " starts," which cause 
much suffering. 
SYNOVITIS. 138 
DISEASES OF THE JOINTS. 
In chronic synovitis, the local phenomena resemble very much those present 
in the acute form, differing from the latter only in their severity. The pain 
of the acute form is replaced in the chronic form by soreness and uneasiness; 
the fluctuation may be even more distinct, the movements less difficult, and, 
if the disease has succeeded the acute form, in pressing over or on moving the 
joint there will frequently be felt a leathery crepitation, occasioned, no doubt, 
by plastic deposits on the synovial membrane. When the intra-articular 
transudation is large, having a watery consistence, the condition is sometimes 
called hydrarthrosis, hydrops articuli, or dropsy of the joint. 
Pathology.-In simple, uncomplicated synovitis, the vascular net-work 
lying beneath the epithelial layer of the synovial membrane becomes dis- 
tended with blood; the fringes or tufts of the membrane are also enlarged 
and abnormal in color. This increased vascularity and the subsequent infil- 
tration render the membrane somewhat red and thickened, and there is an 
accompanying free transudation of serum into its cavity. The presence of 
this serum, and some small fragments of flocculent fibrin, mingled with the 
synovia, render the liquid contents of the joint slightly turbid. As the in- 
flammation subsides, and the transudation becomes absorbed, the inflamma- 
tory changes in the synovial membrane gradually disappear, leaving its 
structure but little, if at all, impaired. 
When the attack has been more than usually severe, there may be, in ad- 
dition to the transudation into the articulation, an infiltration into the synovial 
membrane, containing large numbers of emigrant cells, with others which 
may be termed native cells, and which probably originate in a proliferation 
of the connective-tissue corpuscles. This plastic infiltration produces a 
thickened and opaque condition of the synovial membrane, in some respects 
resembling that seen in the serous membrane of the chest after an attack of 
pleuritis. 
In cases of this kind, the nutrition of the cartilages may be slightly 
changed, and the fluid in the sac of the synovial membrane somewhat puru- 
lent. Even with this degree of inflammatory change, the tissues affected 
may return to their original condition. 
Treatment.-The treatment of synovitis will be determined by its severity, 
and also by the nature of its producing cause. When it is the result of in- 
jury, perfect rest should be secured to the joint, by placing the limb in an easy 
position and supporting it on an immovable splint. The matter of position 
is very important. The limb should never be entirely straight, but should 
be slightly flexed; for when placed in this attitude the degree of pressure 
between the ends of the bones is lessened. If the tenderness and pain are 
severe, blood should be drawn by leeches, or by cups, applied near the artic- 
ulation if the surface is sufficiently ample. The blood-letting should be fol- 
lowed by cold, which can most conveniently be applied by means of ice-bags. 
Pain must be controlled by opiates, and the bowels regulated by the occa- 
sional use of some saline laxative. Should the inflammation not yield to 
these measures, and the swelling of the joint become more consistent and 
firm, the use of alterative doses of a mercurial will be followed by the best 
results. The diet should consist of milk, toast, tea, and other simple articles. 
When the disease has a rheumatic origin, cold applications will be obviously 
improper. Rest of the limb is an essential part of the treatment. A purge, 
consisting of calomel, followed by castor oil or the citrate of magnesia, will 
remove any irritating accumulations which may exist in the bowels, and at 
the same time correct the intestinal secretions, and it will prepare the way 
for such remedies as are known to exert a favorable influence over rheu- 
matic disease. Among these nitrate of potash occupies a conspicuous place. 
From one to two drachms of the salt may be dissolved in a pint or a pint 
and a half of water, and drunk in the course of twenty-four hours. In ad- 
dition to this, ten or fifteen drops of the wine of the root of colchicum may 
be given once in four hours; or, what answers equally well, a quarter of a 
grain of the alcoholic extract of colchicum and five grains of Dover's pow- CHRONIC SYNOVITIS. 
139 
der, made into a pill, and administered every three hours. Salicylic acid, 
from its known power to lower the temperature and to produce an active 
condition of the cutaneous glands, has been extolled by some writers as a 
valuable remedy in rheumatic synovitis; and I can from my own experi- 
ence speak favorably of its action in a number of cases. Quinine, especially 
if there is reason to suspect the presence of a miasmatic element in the dis- 
ease, is among our most valuable remedies. 
When the acute stage of the attack has passed over, but there still remain 
considerable swelling and articular tenderness, much relief may be derived 
from the application of a large blister over the joint, and the internal use of 
iodide of potassium associated with wine of colchicum. Ten grains of the 
former with eight drops of the lattei' may be given to an adult, with some 
water and syrup, four times every twenty-four hours. As soon as the joint 
will bear handling, it should be gently moved, in order to prevent any per- 
manent stiffness. 
Chronic Synovitis differs from the acute form of the disease chiefly in the 
symptoms being less severe. The joint is not entirely free from pain, or, rather, 
the feeling complained of is one of soreness and uneasiness; and the move- 
ments of the articulation can be made, up to a certain degree, without any 
acute suffering. The swelling and fluctuation may be even more noticeable 
than in the acute variety, constituting, as has been observed, what is com- 
monly known as hydrarthrosis, hydrops articuli, or " dropsy of the joint,"- 
names founded entirely on the thin, serous, watery character of the fluid 
within the articulation. 
Chronic synovitis usually succeeds the acute, especially when the lattei* 
has not been vigorously combated. 
Treatment.-The treatment is always tedious, and often very unsatisfac- 
tory. The inflammatory changes frequently extend beyond the limits of 
the synovial membrane, and the joint is left in a weakened condition by the 
imperfect or embarrassed circulation incident to the plastic deposits in the 
synovial membrane and its surrounding connective tissue. The ligaments, 
in many instances, from participation in the inflammation, have lost theii- 
pliability. 
Local and constitutional remedies will be demanded. The limb must be 
placed at rest by plaster or by leather splints so adjusted that they can be 
removed at pleasure. The joint should next be covered w'ith a large blister, 
or smaller ones may be used, repeated at short intervals, and applied to dif- 
ferent parts of the articulation. These may be followed by the use of stim- 
ulating liniments, such as linimentum saponis to which has been added some 
iodide of potassium and oil of amber. Pressure*either by a flannel roller 
or by adhesive strips carried about the joint, will prove a valuable adjunct 
to the other topical applications. 
Internally, the iodide of potassium, when long continued, is capable of 
effecting great good, and, if the general health is impaired, cod-liver oil at the 
same time may be advantageously administered. 
When the inflammation has been removed, which may be known by the 
disappearance of the swelling, the absence of tenderness, and the greater 
freedom of movement, the functions of the joint will be more perfectly re- 
stored by the use of cold or warm douches, as may best comport with the 
feelings of the patient. The douche should be followed by frictions, massage, 
and systematic movements; at the same time the support of the articulation, 
by strips of diachylon, gum ammoniac, or soap-plaster, must not be neglected. 
Benefit will also be derived from the free use, over the surface of the joint, 
of the compound solution of iodine, follow'ed by a few turns of the roller 
bandage. 
When the articulation remains sore and somewhat stiff, becoming heated 
and uncomfortable towards evening, I have found very decided relief to 
follow the application, every night, for a short time, of a poultice consisting 140 
DISEASES OF THE JOINTS. 
of bran, salt, and vinegar. The materials composing this poultice should be 
placed in a bag or between two pieces of muslin, which may be basted, in 
order to keep the ingredients equally distributed. After being thus prepared, 
the bag can be dipped into some hot vinegar, and, having been wrung out, 
should be placed around the joint and covered with oiled silk. 
When, despite all these measures, the fluid does not diminish, it will be 
proper to aspirate the joint and again resort to local alteratives. Should a 
second accumulation follow, the only prospect of cure will be by injection. 
This is accomplished in the following manner. After aspirating, and 
allowing a small amount of the fluid to remain, two or three drachms of 
tincture of iodine should be thrown through the canula into the joint. 
The remainder of the fluid being removed, after a short time, and the 
opening covered with a strip of adhesive plaster, the limb should first be 
placed in a position very slightly flexed, and then thoroughly immobilized. 
The effect of the injection should be to kindle up a certain degree of in- 
flammation, which, gradually subsiding, is followed by the cure of the 
original form of the disease. 
In syphilitic synovitis, no remedy possesses so controlling an influence 
over the affection as iodide of potassium, either with or without the addition 
of bichloride of mercury. 
Strumous, pycemic, and gonorrhoeal synovitis will be noticed in their appro- 
priate places. 
Passive Synovitis.-There is a variety of synovitis which, because of 
the absence of all the local symptoms ordinarily characterizing the disease, 
except that of swelling, may be termed passive. 
Without the concomitant signs of tenderness, pain, and abridged move- 
ment, the patient suddenly discovers that the articulation is very much 
swollen and the fluctuation singularly distinct, on account of the watery 
nature of the fluid. 
Females, I think, are more frequently thus affected than males. This 
affection occurs in constitutions which are feeble. Bichet was disposed to 
regard this condition as non-inflammatory, inasmuch as the synovial mem- 
brane, in those cases which afforded an opportunity for examination, was 
found to be even paler than in health. This appearance of the membrane 
does not, however, argue that there has been no pre-existing inflammation. 
The absence of color is readily accounted for by the depleting effects of the 
free transudation. 
The treatment will not differ from that employed in chronic synovitis. 
When the effusion does not diminish, it should be removed by aspirating 
the joint, and, if necessary, by subjecting it to an injection of tincture of 
iodine. 
When, after an attack of acute or chronic inflammation, the joint is left in 
a state of partial oi* entire immobility, it is said to be anchylosed. This im- 
mobility may occur when the limb is either flexed or extended. The Greek 
term from which our English word anchylosis is derived, was originally 
used to express that form of articular rigidity which occurred in the flexed 
state of the limb, whilst another Greek word, was applied by Galen 
to a similar stiffness when the limb was straight. At present the word an- 
chylosis is used to express immobility of an articulation in any position. 
There are two kinds of anchylosis,-true and false, or complete and incomplete. 
ANCHYLOSIS. 
Complete or True Anchylosis consists in the union of the articular ends of 
the bones by means of osseous material. The uniting bone may be intra- 
articular, extra-articular, or both. When within the joint, it has been pre- 
ceded by more or less complete inflammatory destruction of both the car- ANCHYLOSIS. 
141 
tilages and the thin lamella? of bone on which they rest. The cancellated 
tissue being thereby exposed, granulations spring up, which, gradually co- 
alescing, become developed into fibrous tissue, which ossifies as in the repair 
of compound fractures, and practically makes the two bones one. This form 
of anchylosis is frequently seen in the hip, knee, and elbow. 
In other instances, a new formation of osseous tissue takes place outside of 
the joint, and bridges over the space between the contiguous bones, rendering 
them immovable,-as is seen in rheumatoid disease of the spine and the knee- 
joint. This has sometimes been regarded as an ossification of the ligaments, 
but improperly. It is not the ligaments which ossify in cases of extra-artic- 
ular deposit. These structures undergo previous softening, and only form 
a scaffolding for the inflammatory infiltration, which is transformed into con- 
nective tissue and finally into callus. In instances of long-continued anchy- 
losis, both within and without the articulation, all the joint-structures have 
been previously obliterated. The condition of osseous consolidation now de- 
scribed is sometimes designated synostosis. 
Incomplete or False Anchylosis may be caused by morbid changes both 
within and without the articulation. 
Those which occur within the joint are, first, the formation of false bands 
or threads, intersecting or uniting adjacent surfaces of the synovial capsule; 
second, the cicatricial contractions of the connective tissue, resulting from the 
union of the granulations in fungoid synovitis; third, the union of the dupli- 
catures of the ligamentous capsule, which, by refusing to unfold, offer a strong 
obstacle to motion. This will be better understood by taking a wet ligament- 
ous preparation of a joint, say of the elbow. When the articulation is flexed, 
the anterior part of the capsule will become corrugated; and when the arm 
is extended, the same kind of wrinkles will form on its posterior aspect. As 
the ligaments are not elastic, this doubling up is absolutely necessary to the 
proper motion of the joint. Now, as these plications are always present, 
whether the limb is flexed or extended, it is not uncommon, in cases of rheu- 
matic and other forms of synovitis, for the folds to become permanently glued 
together and thus resist the movements of the joint. These changes are not 
inconsistent with a continuance of the cartilages of the articulation, though 
the latter will be more or less altered in color, elasticity, and form. These 
intra-articular adhesions or cicatrices, at first soft, become firmer by age, and 
may finally undergo ossification. Fourth, the synovial capsule and the liga- 
ments may be so completely changed by inflammatory deposits and their 
organization as to lose all their original characteristics of smoothness and 
flexibility, and may become contracted to a degree which will render move- 
ment impossible. 
The extra-articular causes of anchylosis are to be found in the contraction 
of muscles, and the inflammatory induration and matting together of the 
tissues in the vicinity of the sinuses which exist about the joint. 
A joint may be stiffened and fixed by the cicatricial contraction which 
follows the healing of burns or scalds. These contractions, as well as those 
resulting from structural alterations in the deeper tissues, are sometimes 
sufficient to produce very considerable displacements of the bones of an 
articulation. 
There is an articular rigidity which is due to inflammatory cohesion of 
the tendons and their sheaths, especially of those tendons which pass over 
a joint. Thus, after a fracture at the lower end of the radius, this condition 
most frequently exists, often causing no small difficulty in restoring the func- 
tion of the articulation of the wrist after the consolidation of the bone has 
been effected. 
There is also a stiffness of the joint resulting from its disuse, which is 
important enough to merit notice in this connection. It is due to the lack 
of synovial and bursal secretion, from the want of the stimulus of motion. 
Even the articular cartilage will undergo fibrous degeneration if an articula- 142 
DISEASES OF THE JOINTS. 
tion remains long unmoved. Ginglymoid joints are more frequently the 
subjects of incomplete anchylosis than ball-and-socket joints. Of the first 
class, the elbow and knee are notably liable to the disease; of the second 
class, the hip furnishes numerous examples. 
Diagnosis.-To determine whether a case of anchylosis be true or false, 
the examination must be conducted under the influence of an anaesthetic. 
The resistance offered by the voluntary muscles is quite sufficient to fix a 
joint which upon the suspension of consciousness by ether or chloroform is 
found to possess considerable mobility. When the consolidation is osseous, 
the articulation will be alike immovable with or without an ana)sthetie. 
Even in fibrous anchylosis, if the cicatricial bands are broad and very short, 
the ends of the bones may be bound together so firmly as scarcely to allow 
of any movement whatever. 
Treatment.-The treatment of anchylosis must be governed by the nature 
of both the remote and the determining causes, and by that of the resulting 
disability. When it originates in a constitutional vice, like struma, or when 
the structures of the joint have been hopelessly disorganized by the ravages 
of any form of inflammation, anchylosis constitutes the most desirable ter- 
mination, and should be favored by all possible measures. The most potent 
of these measures is immobilization, secured by placing the part upon an 
accurately fitting splint. 
The surgeon must see that, before this is allowed, the limb is placed in a 
proper position for future usefulness. Unfortunately, this precaution is often 
overlooked. It is by no means an uncommon event to witness cases in which 
the femur has been permitted to become solidly fastened in the acetabulum, 
with the thigh flexed on the abdomen; or the knee-joint immovably fixed, 
with the leg flexed at almost a right angle with the thigh ; or the elbow stiff, 
with the forearm extended in a line with the arm. Accordingly, when a 
faulty position is observed, it must be corrected at the earliest possible mo- 
ment, as time rapidly intensifies the rigidity, not only by shortening the 
fibrous adhesions, but by transforming them into bone. 
There is. however, a large number of cases in which it is proper to resist 
the tendency to anchylosis, or to overcome it when it already exists. Ex- 
amples of these cases are, when it results from sprains, dislocations, and 
fractures, or when it follows an attack of articular or pysemic rheumatism. 
With a view to prevention, the value of an early and vigorous treatment of 
the primary disease or injury-that of which the anchylosis is a sequence- 
will be apparent. 
Whenever the inflammation of an articulation is acute in its character, the 
plasticity of the transudation, and consequently its tendency to organization, 
will be materially lessened by the local abstraction of blood, the administra- 
tion of a brisk purgative, and the application of a blister, accompanied with 
rest of the joint, for the first few days of the attack. 
As soon as the active symptoms have been subdued, very gentle movements 
of the articulation should be made, with a view to sever any adherent threads 
of lymph which maybe present, and to secure their absorption. These move- 
ments must necessarily be practiced with the greatest caution and delicacy at 
first, until the tolerance of the joint is ascertained, when, if the inflammation 
is not revived, they may be repeated, and with greater freedom at each suc- 
cessive manipulation. 
In incomplete anchylosis (or that due to false bands of cicatricial tissue, or 
to close adhesions within the joint, which have occurred either through 
neglect or in defiance of prophylactic measures), it will be necessary, in order 
to correct a faulty position or to restore the ordinary movements of the 
articulation, to resort to the use of force, and, not unfrequently, to tenotomy. 
It is proper, before describing the manner of effecting the disruption, to 
state that, while mobility can generally be re-established, it will rarely be 
as complete and free as that normally belonging to the joint. ANCHYLOSIS. 
143 
The force necessary to overcome false anchylosis may be either manual or 
instrumental. The older surgeons used the latter, applying the force by 
mechanical appliances, all of which wrnre designed to act gradually. These 
appliances have been greatly improved in later times, and are still occasion- 
ally employed, as will presently be noted. 
Anaesthesia, by its power to relieve pain and to relax muscular contraction, 
has rendered signal service to the surgeon in the treatment of anchylosis. 
It was Langenbeck who, in 1846, first demonstrated the facility with which 
deformed joints could be straightened by the use of chloroform. Under the 
operation of this agent the muscles were wholly removed from the influence 
of the will, and allowed themselves to be elongated without opposition; 
whereas without an anaesthetic the resistance would have been so energetic 
that nothing short of tenotomy could have successfully overcome the spas- 
modic action. 
In applying manual force with a view to correct anchylosis, that portion 
of the limb above the stiff' joint must be firmly fixed upon a table with one 
hand, while the portion below is grasped and moved with the other. For 
example, when the elbow-joint is found flexed and stiff after etherization, 
the arm must be the part fixed, and the forearm the part moved. When the 
knee-joint has been the subject of angular anchylosis, it will be found most 
convenient, after etherization, to turn the patient upon the abdomen and 
breast, in which position the leg can be handled with greater advantage. 
When the elbow or the knee has been left anchylosed in a straight position, 
the disruption of the adhesions will be most readily effected by bending the 
joints over the knee. 
Great caution and gentleness are to be observed at the commencement of 
all these manual efforts. The part should be moved for some time backward 
and forward without using much power. As the rigidity begins to yield, and 
the extent of the motion increases, a greater degree of force may be ex- 
ercised. The progress of the operation will frequently be announced by the 
rupture of the adhesion and the cicatricial bands, the crackling of which 
may be both felt and heard as the parts are moved. 
Rashness in the incipient steps of this manipulation may result in frac- 
ture, especially if the anchylosis is one which has succeeded rheumatism, or 
occurs in an aged person, in whom the conditions favor a structural change 
in the bones, rendering them more than ordinarily brittle. I once, notwith- 
standing that the greatest prudence was observed in handling the limb, broke 
the neck of the femur outside of the capsular ligament when endeavoring to 
overcome a soft anchylosis of the hip-joint; and 1 witnessed a similar accident 
happen to a surgeon who, in attempting to break up the rigidity of a knee- 
joint, severed the femur at its lower third. 
After the rupture of the articular adhesions, and when the function of the 
joint has been measurably re-established, it may be found that its full mo- 
tion is still opposed by the shortened state of some of the muscles, or by 
contraction of an adjoining aponeurosis, in which event their subcutaneous 
division will be indicated. 
After the resistance has been surmounted, and the evil position corrected, 
a splint should be applied before the patient comes from under the influence 
of the anaesthetic, so as to maintain the advantage already gained. 
Although it is often requisite to exert very great force before the joint can 
be loosened, it is surprising how little pain, swelling, or other inconvenience 
is afterwards experienced by the patient. Should, however, active local 
symptoms follow, the use of cold anodyne lotions, as lead-water and lauda- 
num, or the application of an ice-bag about the articulation, with the exhi- 
bition of anodynes, administered either by the mouth or hypodermically, 
will generally promptly remove the inflammatory disturbance. When the 
object is merely to correct a vicious posture of a limb, and not to obtain 
permanent mobility, the splint may be allowed to remain ten days or two 
weeks, unless it should create uneasiness by making undue pressure at some 144 
DISEASES OF THE JOINTS. 
point on the surface of the limb, in which case it must be removed and re- 
adjusted. 
When the object is to secure permanent mobility, it will be necessary, after 
breaking up the adhesions and waiting for three or four days for the joint 
to lose its tenderness and heat, to begin passive movements, and to repeat 
these daily more and more energetically, until the plastic and other products 
of inflammation have been rubbed down and absorbed. The patient should 
also be encouraged to practice the various movements of the limb, using it 
in any way that may conduce to the motion of the joint. 
When the disruption of the anchylosis has been effected by manual force, 
or in cases where the patient will not consent to this measure, the malposi- 
tion of a joint may be lessened or often be gradually corrected by the em- 
ployment of an apparatus which, through the operation of a screw, can be 
made to straighten or to flex the limb in a very gradual manner. The in- 
struments represented in Figs. 1014, 1015, 1016 are among the best contri- 
vances for this purpose. 
When the lower limb is the subject of the disease, 
and the adhesions are broken up, the deformity 
may often be corrected by gradual extension with 
adhesive plaster, weights, and pulleys. 
True anchylosis, oi' that in which the union of 
the articular ends of the bones is osseous, requires 
for its correction some- 
thing more than the em- 
ployment of force. When, 
after articular disease, a 
joint is left immovable by 
a new formation of bone, 
the limb being in a posi- 
tion favorable for use, no 
surgeon would for a mo- 
ment contemplate any 
interference whatever. 
Unfortunately, however, 
through ignorance or 
carelessness in the man- 
agement of articular disease, anchylosis is sometimes permitted to occur in 
positions of the affected joint which entail not only deformity, but serious 
disability, the correction of which becomes imperative. Until the time of 
Dr. John Rhea Barton, such cases, 
regarded as irremediable by any con- 
servative method, were doomed to 
amputation. This surgeon, in 1826, 
in the case of a sailor whose thigh 
was flexed and adducted to a degree 
which rendered the limb entirely use- 
less, conceived and successfully exe- 
cuted an operation for the correction 
of the evil, which really marked a 
new era in the surgery of deformities. 
This consisted in exposing the femur 
by a crucial incision over the tro- 
chanter major, isolating the bone in 
this situation from the surrounding 
parts, and dividing it with a saw, 
after which the limb was immediately 
straightened. In order to establish an artificial joint, at the expiration of 
three weeks passive motion was instituted, and at the end of four months 
the man was able to move about with only the assistance of a cane. 
Fig. 1014. 
Fig. 1015. 
Apparatus for straightening the 
knee. 
Apparatus used in anchylosis of 
the elbow. 
Fig. 1016. 
Anterior splint, with a Stromeyer screw, for extending 
anchylosed elbow. ANCHYLOSIS. 
145 
Two modifications were made of Barton's operation, one by Dr. Kearney 
Rodgers, in 1830, and the other by Professor Sayre, in 1862. Both of these 
operations were executed in the upper part of the femur. That of Rodgers 
consisted in excising a wedge-shaped portion of bone from between the tro- 
chanters, thicker at the inner than at the outer side, and establishing an 
artificial joint at the point of separation. 
Sayre, while dividing the femur at the same point, very ingeniously cut 
out the segment in such a manner as to initiate a ball-and-socket joint. This 
he did by giving a concave shape to the lower end of the upper fragment, 
and rounding the upper end of the lower fragment. This operation was 
performed twice by Professor Sayre, and in each instance with the effect of 
establishing a movable joint. One of the patients was living in 1876; the 
other died six months after the operation, from disease of the lungs. A post- 
mortem examination showed that the new joint possessed a capsular ligament, 
two round ligaments, and a synovial membrane, and that the articulating 
surfaces of the bone were tipped with cartilage. 
In 1870, Mr. William Adams, of London, made a subcutaneous division of 
the neck of the femur for anchylosis with deformity. The patient was an 
adult, and, in addition to the section of the bone, it was necessary to divide 
the tendons of several muscles before the limb could be brought into a proper 
position. Recovery followed by anchylosis. 
The instruments required for this operation are a long, delicate knife and 
a saw with a cutting edge extending about an inch and a half from its ex- 
tremity. The knife is passed through the soft parts to the bone, in order to 
open a way for the saw. After the withdrawal of the knife, the saw is con- 
ducted flatwise along the tract until the femur is touched. It is next turned 
over the front of the femur, and, by the usual movements, made to cut its 
way gradually through. (Figs. 1017, 1018.) 
Fig. 1017. 
Adams's knife. 
Fig. 1018. 
Adams's saw for subcutaneous osteotomy. 
Mr. Maunder, instead of the saw, uses a narrow chisel for cutting the 
bone. 
Anchylosis of the knee-joint.-In attacking anchylosis of the knee-joint, several 
modifications of the original method of Barton have been made. Dr. Gurdon 
Buck, in 1844, instead of excising the wedge-shaped piece from the femur, 
above the condyles, removed it directly from the obliterated joint, including 
not only the condyles, but also the patella and a part of the head of the 
tibia. This surgeon, in another case, made an excision of the knee-joint. 
The relative merits of the two methods have been pretty accurately 
ascertained by the statistics of Dr. S. W. Gross, who has collected 14 cases 
of Barton's operation, with only 2 deaths, and 33 cases of Buck's operation, 
to which may be added another excision at the knee, done at the Philadel- 
phia Hospital, with a fatal result, making in all 34 cases, with 28 recoveries 
and 6 deaths, the percentage of fatal cases being nearly the same in both 
operations. 
The subcutaneous method of division has also been applied to correct 
VOL. II.-10 146 
DISEASES OF THE JOINTS. 
vicious anchylosis of this articulation. This, as in the open plans already 
described, is executed either through the old site of the joint or above it. 
Thus, Dieffenbach suggested the division of the osseous band with the chisel 
and saw, and Malgaigne, with the chisel and mallet. Langenbeck first bored 
a hole almost through the joint, and, introducing a narrow saw, cut first in 
one direction and then in the other, thereby weakening the bone to an extent 
which rendered fracture an easy task. 
The perforation of the bone with a drill above the joint, with a view of 
fracturing the femur, was proposed by Brainerd, of Chicago, in 1854. The 
same surgeon subsequently drilled the joint, with the same object in view, 
namely, to enable him by force to sever the consolidation. 
Professor Joseph Pancoast demonstrated the feasibility of the first plan 
in a case of deformed anchylosis of the knee-joint, by boring a number of 
holes through the femur a short distance above the condyles and fracturing 
the bone. 
I repeated successfully this operation on a young man in the Phila- 
delphia Hospital, whose leg was anchylosed at a right angle with the 
thigh; and again at the Pennsylvania Hospital, upon a minor, whose leg 
was very much in the same position, and with a like favorable result. 
(Figs. 1019, 1020.) The operation was performed in the following manner. 
The patient having been etherized, a 
sharp-pointed tenotome was entered at 
the outside of the thigh, just above the 
base of the condyles, and pushed down 
to the bone. On its being withdrawn, 
a drill was inserted into the same place, 
carried to the same depth, and made to 
pierce the femur, by giving a rotatory 
motion to the instrument. This done, 
and without removing the drill from the 
external wound, it was passed through 
the bone at another point, near to the 
joint. This was repeated a number of 
times, until the osseous tissue was so 
honeycombed that, by the use of a little 
force, the thigh was broken over the end 
of the table. The limb was now straight- 
ened and placed in a fracture-box, and a 
weight was suspended from the leg. The sides of the box were brought up, 
which, with the pillow it 
contained, exerted suffi- 
cient pressure against the 
sides of the extremity to 
prevent lateral displace- 
ment. 
The drill might be driven 
with greater ease, and the 
operation shortened, if, in- 
stead of being worked by 
the hand, it were attached 
to the arm of the surgical 
engine. The division of the femur might also be effected by the Adams 
saw. 
Professor Gross, after perforating the callus of the knee-joint in different 
directions, divided the remaining bridges of bone with the chisel and mallet. 
Resection is the last method of overcoming a faulty anchylosis of an 
articulation which I shall mention, and certainly one that should be, under 
any circumstances, the last expedient to which the surgeon should resort. 
In deciding upon the course to be pursued in anchylosis, it will be proper 
Fig. 1019. 
Appearance of limb before operation. 
Fig. 1020. 
Appearance of limb after operation. CARTILAGE DEGENERATION. 
147 
to consider-first, the exact amount of disability which the stiffness of the 
joint entails; and, secondly, the particular articulation involved. A finger 
may be fixed even in a bad position, and yet may not materially interfere with 
the ordinary use of the hand. The wrist may undergo osseous consolidation, 
and although subjecting the patient to very great inconvenience, yet in time, 
and under the spur of necessity, the fingers and arm will learn in a hundred 
ways to supplement the defect. And so it is true of the elbow; after chronic 
articular disease, it may be left solidly fixed at an angle unfavorable for con- 
veying food to the mouth, for tying a cravat, or adjusting the hair, yet such 
is the mobility of the scapula that, under the urgency of the circumstances, 
a range of movement may be obtained for the arm that is truly wonderful. 
Even when the knee is anchylosed at a moderate angle, the disability is often 
provided for by a properly-constructed shoe. Whenever, therefore, through 
the vicarious offices of other parts, or by ingenious mechanisms, the evils of 
an anchylosis can be reasonably well endured, it is the wisest course, in view 
of the risks attending all operations, to advise against such procedures. 
There will, however, still remain a considerable number of cases in which, 
in consequence of the extent of the deformity and the resulting disability, 
interference becomes imperative. And when this is the case, the next ques- 
tion to be determined is, what particular one of the various methods described 
will be best adapted to accomplish the desired result. 
It may be observed here that no single operation will meet the require- 
ments of any case of anchylosis. When the hip is the articulation affected, 
the operation of Mr. Adams-that of making a subcutaneous section of the 
neck of the femur, or of its shaft, lower down, with a saw-should be pre- 
ferred. And the same operation will be equally appropriate to anchylosis 
of the scapulo-humeral joint. When the knee-joint is involved, the femur 
should be drilled, subcutaneously, above the condyles, and the bone fractured. 
In anchylosis of the elbow-joint, a similar operation on the humerus, near to 
its condyles, will be preferable to excision, or to boring and chiseling through 
the articulation. Indeed, when the normal joint tissues have all been de- 
stroyed, and their places are occupied by a large mass of callus, it is impossible 
to execute a strictly subcutaneous division of the bones. 
In anchylosis of the ankle, when the foot is in a bad position, it will be a 
nice question to determine which will be the preferable operation,-excision 
or amputation. Amputation is attended with less risk than excision, and 
this fact should, in most instances, decide the selection. 
There are occasionally witnessed two morbid conditions of the synovial 
membrane of a very singular nature. The first has been named the fimbriated, 
and is characterized by the presence of numerous whitish growths, having a 
sessile or a pedunculated attachment, varying in size from that of a mustard- 
seed to that of a pea, and growing from the inner surface of the membrane. 
(Fig. 1021.) These pendulous masses are formed of connective tissue, and 
have an inflammatory origin, excited, some think, by a rheumatic state of 
the system. 
The second condition is one in which the outgrowths are situated similarly 
on the inner surface of the synovial membrane, and are also fibroid in their 
character, but are flattened, and resemble, in form and size, the seed of a 
melon. (Fig. 1022.) 
In the movements of the joint, both of these singular formations are liable 
to be rubbed off from their attachments and to fall into the joint, provoking 
the same trouble which follows when other movable bodies enter the articula- 
tion. 
Cartilage Degeneration. 
The cartilages of an articulation, though designed to fulfill a mechanical 
office,-that of defending the ends of the bone against the wearing effects of 
Fibroid Formations in the Synovial Membrane. 148 
DISEASES OF THE JOINTS. 
pressure, besides diminishing friction, and by their texture and elasticity 
neutralizing the effects of concussion,-are, nevertheless, living structures. 
Fig. 1021. 
Fig. 1022. 
Fimbriated synovial membrane.-Pirrie. 
Knee-joint exposed, exhibiting the synovial mem- 
brane covered with bodies of melon-seed shape.- 
Druitt. 
The fact that, in a popular sense, they are non-vascular does not make them 
independent of the blood-vessels for the materials on which they subsist. 
Their nutrition is effected through the agency of cells, -which is no less true 
of the other tissues of the body; the only difference is, that the attractive 
power of the cells upon the contents of the vessels is exerted at a greatei' dis- 
tance than is usual in other structures; or, to use a commercial phrase in 
elucidating a vital process, the cartilage-consumers are compelled to transport 
their supplies a considerable distance from the point of delivery. 
The pathology of Goodsir, Redfern, Rindfleisch, and others, which refers 
the ulceration of cartilages to alteration of the cartilage cells, independent 
of the blood-vessels, is rendered improbable by the very fact that it invades 
the unity of a general law to meet an exceptional case, and that a case predi- 
cated only upon an assumed limitation of the reciprocal influence exerted 
between the blood and the cells of a tissue. 
The blood-vessels concerned in the nutrition of the cartilages are those of 
the plications of the synovial membrane, situated at the margin of the car- 
tilages, where the latter are covered by an extension of the periosteum, and 
also those beneath the articular lamellae of the bones. Hence it is not im- 
proper to speak of fatty metamorphosis, hypertrophy, atrophy, ulceration, 
and other degenerations of these structures which accompany inflammation. 
Weber did not deem articular cartilages exempt from inflammatory changes. 
The synovial membrane cannot be long the subject of these changes without 
the nutrition of the cartilages becoming deeply affected. Generally their 
involvement is secondary, and due to an extension of disease from the mem- 
brane or from the subjacent bone. It is thought by several writers that 
this is invariably the case, and that these structures never undergo primary CARTILAGE DEGENERATION. 
149 
change,-an opinion in which I do not concur. I am confident that in certain 
forms of violence, when the articulating ends of the bones are forcibly im- 
pelled against each other, the nutrition of their cartilaginous covering is 
sometimes markedly affected, in consequence of the contusion to which they 
have been subjected, before any structural alteration is noticed in other por- 
tions of the joint. Opportunities for observing such changes are not in- 
frequently offered in cases of railroad accidents, in which the articulations 
are often laid open. 
The degenerative changes which the cartilages undergo may commence 
either upon the free or upon the attached surface, according as the arthritis 
arises from the synovial or from the osseous structure. Some of these changes 
are readily detected by the naked eye. First, the cartilage loses its natural, 
pearly, glistening appearance, and becomes cloudy. It also swells and softens, 
possessing often so little resistance as to admit of being crushed between the 
fingers, and, after a time, it can be easily peeled off from the bone. In other 
instances a highly vascular layer, or a granulation layer of the synovial 
membrane, covers the surface of the cartilage, which, when stripped off from 
the latter, exposes a rough, irregular surface, as though these granulations 
had grown into the substance of the cartilage and consumed it. This, under 
certain limitations, is the case. Billroth has pictured the destructive effects 
of granulations when growing into the cancelli of carious bone; and the same 
process may be repeated in ulcerating cartilage; but it is conditioned upon 
pre-existing alterations in the cells of the structure. These alterations con- 
sist in proliferation and granular degeneration of these bodies, forming in the 
hyaline matrix irregular cavities, sometimes at one part and at other times 
in several parts of the intercellular substance of the cartilage, and which, 
opening upon the surface, give to the latter a rough, irregular, worm-eaten 
appearance. This granular condition extends also to the matrix, which 
loses its homogeneous appearance and gradually disappears. As this process 
advances, the cartilage, especially when the invasion has been from the 
osseous side, loses its connection with the bone, and on the application of 
slight pressure it may easily be stripped off from the latter. 
If the degeneration continues to advance, one portion after another of the 
cartilage is consumed. A necrosed fragment often becomes detached, and 
falls free into the joint, until finally the whole structure disappears and the 
end of the bone becomes exposed. This form of cartilage change is more 
commonly met with than any other, and is that which is present in cases of 
arthritis arising from strumous or tubercular disease. 
Symptoms.-The symptoms denotive of cartilage degeneration are not 
always very pronounced. Indeed, there are not wanting instances in which 
very considerable destruction of this part of a joint has taken place before 
the disease has even been suspected. The intense, deep-seated nocturnal 
pains and muscular starts, which were considered by Sir Benjamin Brodie 
as pathognomonic of the lesion, cannot properly be referred to this source. 
For cartilage, being destitute of nerves so far as we know, must be insensible. 
Yet, as these signs point to a disease of the underlying bone, the degeneration 
of the cartilage, when these indications are present, may be inferentially 
assumed.. 
Of more significance is the grating crepitation so often noticed, and also 
the preternatural movement of the articulating ends of the bones when forced 
in opposite directions,-a movement resulting either from the disappear- 
ance of the cartilages, from the softening of the ligaments, or from both causes 
combined. 
Fibrous Degeneration.-As this transformation appears to be connected 
with a peculiar disease, often described as rheumatoid arthritis, I shall con- 
sider it under that head. 
Changes in the Articular Ends of the Bones in Arthritis.-There is a peculiar 
interest connected with the epiphyses of the bones. Very many cases of 150 
DISEASES OF THE JOINTS. 
joint disease unquestionably begin in the articular extremities of the bones. 
The inflammation which commences in these parts may pursue either an 
acute or a chronic course, and may originate in the periosteum or in the 
cancellated tissue. It may be the result of local causes, such as cold or trau- 
matic violence, or may depend on a constitutional state, as syphilis, rheu- 
matism, or tuberculosis. Occurring in the young, it is very frequently the 
effect of a pre-existing constitutional vice derived from tubercular antece- 
dents. 
The subject of strumous or scrofulous disease of the joints is one about which 
there exists considerable diversity of opinion. While some would altogethei* 
abolish the term, as exercising a pernicious influence over the treatment of 
these affections, others, on the contrary, go so far as to affirm that, in chil- 
dren, the disease invariably arises from a diathesis of this nature. I regard 
both views as extreme and without any support, either in the light of modern 
pathology or in experience. Any extended discussion of this vexed question 
here would be unprofitable. But I may state that I cannot conceive how any 
one who has attentively studied this subject can take such extreme ground 
as to deny altogether the existence of an inflammation of the joints depending 
on a constitutional condition. The statement that in many cases of so-called 
scrofulous joint disease, dissection has failed to discover any tubercular de- 
posit in the bones or elsewhere, or that the excision of diseased articulations 
has not been followed by a recurrence of the affection, will fail to satisfy the 
professional mind that there is no connection between a peculiar condition 
of the system and certain articular diseases. The deposition of tubercle in 
the epiphysis is not, in my judgment, prerequisite for the existence of the 
form of joint disease under consideration, though such a product in this situ- 
ation is not uncommonly found; how often, it is difficult to determine, as 
few opportunities are afforded us for an examination of the bone in the com- 
mencement of the disease. The existence of a peculiar organization is all 
that is required. This is most frequently revealed by the presence of the 
characteristics of the lymphatic .temperament; or, as has been stated by 
Professor Gross, a mixture of the lymphatic and sanguine temperaments. 
The failure of the disease to reappear after excision does not in any way 
militate against the hypothesis of its constitutional origin. Enlarged lym- 
phatic glands, the strumous paternity of which no one would challenge, may 
be removed with equal certainty that there will be no return of the growth. 
Aside from these considerations, upon what theory, other than that of a con- 
stitutional origin, can we explain the thin whey-like and curdy pus which 
belongs to these joint-affections of children ? Again, if only local in their 
origin, why do not such affections yield to local measures of treatment, which 
prove so effectual in other forms of articular inflammation, instead of de- 
manding years for their subjugation, and finally ending, in a large number 
of cases, under the most skillful treatment, in anchylosis, or in a complete 
disorganization of the articular components of the joint? Confronted with 
such facts, I am not prepared to reject altogether the old doctrine of consti- 
tutional organization predisposing to arthritis in young persons. This may 
be quite as appropriately expressed by strumous disease as by any other 
term. 
ARTHRITIS. 
By the term arthritis is understood an inflammation of a portion, or of all, 
of the components of an articulation. It may be acute or chronic in its 
nature, and may arise from causes of a local or of a constitutional character. 
Among the local causes are wounds, bruises, sprains, concussions, and the 
combined influences of cold and moisture. Arthritis arising from local 
causes in most instances commences as a synovitis, the inflammation sub- 
sequently extending to the other textures of the joint. 
The constitutional causes of arthritis are rheumatism, gout, exanthematous 
disease, pyaemia, diseases of the kidneys, and tuberculosis or struma. When ARTHRITIS. 
151 
arthritis has a rheumatic or a scrofulous origin, the bones and the cartilages, 
and sometimes the ligaments, become implicated before the synovial membrane. 
When the articular inflammation occurs as a sequel of scarlatina, albumi- 
nuria, or pyaemia, it is the result 'of blood-poisoning, and commences as a 
purulent synovitis. I once witnessed a case of pysemic arthritis in a boy 
of about thirteen years of age, who had been wounded by the horn of a cat- 
tish ? all the visible articulations of the body were involved. A promising 
young physician of Philadelphia, who died of albuminuria, in the course of 
his disease was attacked with a suppurative synovitis of the wrist-joint. 
The arthritis which sometimes attends the puerperal state, as also that 
which is occasionally seen to follow urethral suppuration, must be referred 
to blood-infection. By some, these forms of disease are considered to be 
metastatic, the synovial inflammation being excited by the transportation 
of spoiled fragments of fibrin or other material through the blood-vessels. 
By not a few writers the gonorrhoeal variety is considered to be of a rheu- 
matic character. 
Aged persons sometimes suffer from spontaneous arthritis,-a form entirely 
defiant of treatment,-the disease not only destroying the affected joint, but 
also extending to the bones beyond. Persons who belong to tubercular 
families, and who escape bone-disease during childhood, I am disposed to 
believe are liable to suffer from this form of arthritis in old age. A prominent 
lawyer of this city, who in the later years of his life was attacked with a 
destructive arthritis, from which he gradually sank and died, informed me 
that when a child he had barely escaped hip-disease. 
Symptoms.-Arthritis may begin in a manner so quiet as not to be recog- 
nized in its early stage. The patient, for some time, complains of only a 
little soreness of the joint, which disappears after moderate exercise, but is 
again experienced towards evening, after the day's duties are over, and oc- 
casions a slight limp in the gait. The discomfort is referred to rheumatism, 
and not until the articulation commences to swell, and the suffering becomes 
severe, is the serious nature of the affection suspected. 
In other instances the invasion of the disease is more pronounced, and the 
pain is acute, deep-seated, and throbbing, attended with evening paroxysms 
of unusual severity, lasting far into the night. As the disease advances, the 
sensitiveness of the limb becomes so extreme that the patient will scarcely 
allow any one to approach near to the bed, as the slightest movement or jar 
of the extremity causes the greatest agony. The attitude of the affected 
member is quite peculiar; it is one which insures the most perfect relaxation 
of the joint-tissues. If the knee is the diseased articulation, the leg is flexed 
on the thigh, and the latter on the pelvis, while the entire limb is slightly 
abducted and rests on its outer surface. 
The pain is not always referred to the same point. When the knee-joint 
is the subject of the inflammation, the lower part of the inner condyle 
seems to be most sensitive. When the disease is in the hip-joint, that part 
behind the great trochanter is the seat of greatest tenderness. When the 
elbow is affected, the parts least tolerant of pressure are those on either 
side of the olecranon. 
Swelling, which is another sign of the disease, presents an appearance 
unlike that seen in uncomplicated synovitis. In the latter, the form of the 
enlargement is determined by the ligaments being much more prominent on 
those aspects of the joint where the least resistance is encountered; whereas 
in arthritis, in consequence of the softening of the texture of the ligaments 
and also from the effusion into the extra-articular fibrous tissue, the swelling 
is equally distributed around the articulation. 
The patient is harassed with involuntary muscular "starts" of the limb, 
which compel him to scream out, and which not unfrequently interrupt his 
sleep or cause him to wake in a fright. 
At this stage of the disease the arthritis may pursue one of two courses: 
First, the inflammation may gradually subside, the pain and swelling vanish, 152 
DISEASES OF THE JOINTS. 
and the joint recover, with the exception of being anchylosed to some extent, 
though this last condition does not necessarily follow. Second, suppuration 
may ensue within the joint and also in the connective tissue exterior. The 
nutrition of the ligaments is disturbed, occasioning their softening and fatty 
metamorphosis to a degree which, in the case of the knee, allows the lateral 
movements to be exaggerated. The extra-articular suppuration is sometimes 
the result of irritation propagated from the inflamed and suppurating syno- 
vial membrane to the subcutaneous and capsular structures, and sometimes 
it is the direct result of purulent extravasation by rupture of the synovial 
sac. Whether resulting from the one or the other cause, the extra-articular 
suppuration is the signal fbr increased constitutional disturbance, such as 
rigors, fever, etc., and for a more diffused, though less prominent, swelling 
about the joint. Abscesses often form in the limb at points remote from the 
articulation. 
Along with preternatural mobility of the joint, a grating crepitation can be 
recognized, if the surfaces of the articulating bones are rubbed or pressed 
together, an evidence that the cartilages are implicated in the disease. These 
are sometimes eroded and extensively destroyed before the ligaments yield, 
giving rise to preternatural mobility of the joint. 
It is proper to state that, in exceptional cases, all the changes which have 
been mentioned may exist, and yet neither crepitation nor undue move- 
ment be detected, a condition which may be explained by the presence of an 
abundant, soft, plastic transudation into the joint, or of a gelatinous trans- 
formation of the synovial membrane. 
After the abscesses are evacuated the swelling of the limb diminishes. 
But there remain sinuses, giving egress to a thin, purulent discharge. This 
may wear out the patient from hectic irritation, unless he is rescued by ex- 
cision or amputation. 
Occasionally, even in the condition of articular disorganization just detailed, 
patients who have youth on their side may recover with an anchylosed joint, 
the discharges gradually diminishing and the sinuses one by one closing up, 
until all disturbance disappears, leaving a stiff and wasted limb. 
Diagnosis.-An extra-articular abscess-the only condition likely to be mis- 
taken for a purulent arthritis-may be recognized by the following signs. 
The movements of the joint are not impaired; the pain is superficial and 
neither tensive nor periodical. The swelling also in the extra-articular ab- 
scess is local, or confined to one aspect of the joint. But in arthritis motion 
of the articulation is attended with great suffering; the pain is deep, throb- 
bing, attended with evening exacerbations, and the swelling is diffused, or 
involves the whole articulation. 
Pathology.-The structural changes incident to arthritis affect more or 
less all the components of a joint. They maybe considered under the follow- 
ing heads: first, changes in the synovial membrane; second, changes in the 
cartilages; third, changes in the bones; fourth, changes in the ligaments. 
Changes in the Synovial Membrane.-The changes which occur in the syno- 
vial membrane as the effects of arthritis are different in some respects from 
those which have been described under the head of acute synovitis, inasmuch 
as in the former the inflammation is chronic rather than acute in its character. 
Injection of the synovial vessels and plastic infiltration of the membrane, 
together with a large serous effusion, constitute the leading phenomena of the 
acute form of arthritis, and if the morbid action be still more intense, it may 
end in suppuration, ulceration, and even destruction of the synovial mem- 
brane. But in the chronic form, that under consideration, the inflammation 
shows no tendency to destroy this structure, but rather to thicken it by 
fibrinous and cell infiltration, much in the same manner as successive attacks 
of pleuritis cause great increase in the thickness of the serous lining of the 
thorax. It is not uncommon, in old cases of chronic arthritis, to find the 
synovial membrane from one-fourth to three-fourths of an inch in thickness. CHANGES IN THE SYNOVIAL MEMBRANE. 
153 
But a still more notable change is the production of a granulation tissue in 
such abundance as to form a thick, grayish, or dark-red, fungous layer, which 
has been termed by Sir Benjamin Brodie the pulpy and by Swain the gelati- 
niform degeneration. This fungoid tissue is moderately vascular, and is filled 
with serum and granular matter, imparting to it a soft, flabby consistence. 
Bonnet and Paquet have each made a chemical examination of this tissue, 
the former finding much fibrin, and the latter, mucin, in its composition. 
Numerous fusiform and stellate cells have been noticed intermingled with the 
other constituents of the jelly-like substance. 
Possessing as it does loops of blood-vessels supported on a basis of fibrin 
with spindle-shaped cell-forms, this singular structure may be regarded as an 
imperfectly organized granulation tissue, and in many respects resembles 
the half-rotten substance which is found in the cavity of a necrosed bone. 
Though Sir Benjamin Brodie believed that this fungoid condition was pecu- 
liar to the synovial membrane of the knee-joint, later observations show that 
other articulations suffer from this same degeneration. Mr. Hodgson has 
seen it in the ankle; Mr. Erichsen, in the elbow; Pirrie, in the shoulder; 
and it has been seen by myself in the wrist. 
The pulpy degeneration, though occasionally met with at all periods of 
life, is more peculiarly a disease of childhood. Its constitutional origin is 
disclosed by the spontaneous manner in which it begins, there being gener- 
ally no antecedent injury to explain its occurrence. 
Symptoms.-This variety of arthritis, at its commencement, manifests itself 
by some stiffness of the joint, attended, when in the knee or ankle, by a slight 
lameness. The swelling of the joint is uniform, colorless, doughy to the feel, 
and without fluctuation. Very little pain is experienced during the incipiency 
of the disease. The presence of a soft, flabby swelling, and the whiteness 
of the skin covering the articulation, are sufficient to distinguish this form 
of synovial disease from an ordinary synovitis. And the fact that the swell- 
ing is uniform all over the joint will also prevent its being confounded with 
disease beginning in the articular extremities of a bone. In the latter case 
the enlargement is limited to the situation of the epiphysis. 
When the disease takes a favorable turn, the swelling gradually subsides 
and acquires a greater degree of firmness, the constitutional excitement is 
lessened, the appetite returns, and the patient begins to manifest a disposition 
to use the limb. While this may be done to a limited extent, it is not 
probable that the movements of the articulation will ever be restored to their 
original perfection. For the conversion of the granulation into cicatricial 
tissue within the joint, and the adhesion thereby of the synovial membrane 
and cartilages, must necessarily materially abridge motion. Indeed, any 
attempt to overcome this rigidity by forcible measures may rekindle the 
original disease into unmanageable activity. 
When the morbid changes continue to progress, the temperature of the 
joint is increased, and the pain, wThich at first was slight, now becomes pecu- 
liarly distressing, and is attended with "jerkings" or "starts," especially at 
the moment when the patient falls into a doze, which immediately interrupt 
his rest. These " starts" are supposed to be caused by the muscles, wThich, 
during the time the patient is awake, are constantly on guard to hold the 
joint-surfaces in the relation most favorable for comfort, but which relax their 
vigilance during the moments of sleep, thus allowing the bones to change their 
position when the occurrence of pain suddenly summons them back to their 
duty. The presence of these involuntary muscular " starts," and the existence 
of deep, gnawing, boring pain, furnish strong presumptive evidence that the 
inflammation has passed from the synovial membrane to the cartilages and 
the bones. This inference will be corroborated if, in addition to the above 
signs, the muscles begin rapidly to waste and the lateral motion of the 
joint is increased. Usually when the cartilages are undergoing ulceration 
a certain amount of crepitation may be discovered if the joint is moved, 
though their rough surfaces may be so covered with the fungoid granulations 154 
DISEASES OF THE JOINTS. 
as to render the sound inaudible. It is under such circumstances also that, 
when the articulating surfaces are forced towards each other, they appear to 
be opposed by some intermediate elastic substance, which is, doubtless, the 
excessive pulpy granulations within the joint. 
Along with these changes suppuration takes place. Its occurrence will 
most likely be attended with increased pain, rigors, and febrile excitement. 
The pus is not always confined to the cavity of the joint; it may force its 
way through the softened ligaments and issue upon the surface of the joint. 
Even before the matter escapes from the synovial capsule, it is not uncommon 
to witness abscesses in the tissue external to the articulation, the openings of 
which long remain as sinuses, through which protrude soft granulations of a 
pale-red color. 
The reflex irritation of the muscles, unless very carefully watched, will 
cause the limb to assume a position which, in the event of anchylosis occur- 
ring, will interfere very seriously with its usefulness. 
Treatment.-The treatment of fungoid arthritis will include both local 
and constitutional remedies. The joint must be maintained in a state of 
complete rest, a condition which can only be fulfilled by the use of a properly 
adjusted splint. 
In order to repress the growth of the intra-articular granulations and to 
favor their removal, external pressure should be made about the articulation. 
This should be done before applying the splint, and may be accomplished 
either by covering in the entire joint with successive strips of adhesive 
plaster (which should extend two-thirds round the limb), or by enveloping 
the articulation with cotton wool and binding it in place by the turns of a 
roller. 
If the inflammation partakes of an acute character, the local abstraction of 
blood, by means of leeches, should take precedence of all other local measures. 
When the inflammation is chronic in its course, the free application of the 
compound solution of iodine is to be preferred. Nor is it necessary, in this 
form of the inflammation, to insist on confinement to bed. An immovable 
splint, formed by a plaster roller, should be applied, including the affected 
limb, and, if the disease is in the lower extremity, the patient should be 
allowed to go about on crutches. When there are severe pains and "jerk- 
ing," nothing so promptly relieves the suffering as extension, by means of a 
weight attached to the limb. 
When the disease shows a tendency to retrocede, the joint may be moved 
cautiously, in the hope of retaining mobility. But if the manipulations create 
any increase of pain it will be better to desist at once. 
It must be remembered, however, that in many cases the local disease is 
only an expression of a constitutional condition, and consequently it is of 
vital importance to address our remedies to the system at large. For this 
purpose cod-liver oil, iodide of iron, tincture of chloride of iron, and quinine 
will prove productive of good effects. The diet must be nutritious, and as 
much as possible the patient should have the advantage of pure air. 
As a cure approaches, the swelling gradually disappears; the sinuses, if any 
are present, gradually contract and close up; the joint becomes more fixed; 
the general health improves, and the patient, after many months or years, 
finally recovers, with an anchylosed joint and a withered limb. 
Articular Disease arising from Constitutional Causes. 
DRY ARTHRITIS, RHEUMATISMUS DEFORMANS, MALUM SENILE RHEUMA- 
TOID ARTHRITIS, OSTEO-ARTHRITIS, ETC. 
The earliest notice of this disease was by Laudre Beauvais, in France. 
Since his time, it has been carefully studied by Dr. Adams and Prof. R. AV. 
Smith, distinguished Irish surgeons, and in England by Dr. Haygarth. The 
joints which suffer most from the affection are the hip, knee, shoulder, tem- 
poro-maxillary, wrist, and those of the vertebral column, or those which, ARTICULAR DISEASE FROM CONSTITUTIONAL CAUSES. 
155 
in the ordinary course of life, are most severely taxed. Though at one time 
believed to be closely allied to gout, the two diseases are at present regarded 
as quite distinct, as in rheumatoid arthritis there does not appear to be any 
constitutional condition which favors the deposition of the urates in the 
joints or elsewhere. The disease frequently attacks simultaneously the cor- 
responding articulations of the two sides. One form of the affection attacks 
the small joints, and from this females suffer more than males. The other 
form {senile) is peculiar to advanced life, and fastens upon the large articula- 
tions in preference to the small. In neithei' variety is there any tendency 
to suppuration or even to anchylosis. 
Causes.-Surgeons are not agreed as to the causes of this singular affec- 
tion. Remak thought that it arose from some irritation located in the spinal 
marrow; and the occasional co-existence of the disease with others depend- 
ing upon certain lesions of the central masses of the nervous system, as 
locomotor ataxia, lends some plausibility to this conjecture. The fact, how- 
ever, that it can be often traced to a sprain or a contusion of a joint, and also 
that it sometimes follows in the wake of an ordinary rheumatic attack, would 
seem rather to indicate its rheumatic relationship. 
Symptoms.- Rheumatoid arthritis is usually foreshadowed by fugitive pains 
and a tired feeling in the affected joint. The pain frequently partakes of a 
neuralgic character, shooting along certain nerves, as the saphenous, or, when 
the knee or the shoulder is attacked, along the circumflex. 
Should the disease fasten upon the vertebral column, these pains pass round 
the body or down towards the hips and the lower ex- 
tremities. Atmospheric changes exercise a marked 
influence on these symptoms. They are usually ag- 
gravated by damp, cloudy weather. After a time, the 
articular movements begin to become impaired ; the 
patient, after a night's repose, experiences consider- 
able inconvenience on first attempting to walk, but the 
stiffness wears away as the day advances. Pressure 
over the joint causes no pain, nor is the skin discolored. 
The joints gradually grow more out of shape and more 
displaced, in consequence of alteration in the form of 
the articular ends of the bones, and a grating noise is 
produced when the surfaces of the bones are moved 
on each other. 
Irregular masses and nodular osseous excrescences 
form about the joint. These growths are in some 
cases sufficient to produce a dislocation of the artic- 
ulation. The most singular distortions follow. The 
fingers are sometimes seen overlapping one another, 
or twisted laterally until a displaced phalanx may be 
even forced through the skin. The thumb generally 
remains unaffected. 
When the spine is affected, the vertebrae are fre- 
quently bound together by bridges of bone, rendering 
the column inflexible (Fig. 1023), and compelling 
the patient to maintain a fixed position of the body, 
in which he is unable to bend forward or to stretch 
backward. Nor is the disease confined to the joint- 
tissues alone. The tendons become rigid and con- 
tracted, and the muscles wasted. The extension of 
the bony masses may be sufficient to compress the 
nerves, as they emerge from the intervertebral foram- 
ina, and to cause paralysis of the muscles to which 
they are distributed. 
Fig. 1023. 
Spinal column from a case of 
rheumatoid arthritis. 
Osteo-Arthritis of Special Joints.-When the hip-joint is attacked, the patient 156 
DISEASES OF THE JOINTS. 
suffers pain in walking. The functions of the joint become increasingly 
impaired, so that difficulty is experienced in bending forward, standing erect, 
or sitting, in which last posture the limb is kept extended. The pelvis 
becomes tilted or oblique, and the rotundity of the buttock is lost in con- 
sequence of atrophy of the gluteal muscles. It becomes flattened, and with- 
out the groove which, in health, so sharply separates it from the thigh. The 
limb also shortens and becomes everted, sometimes inverted, and, when 
rotated, gives rise to a rude crepitation. Though the nates and the thigh 
waste, yet it has been observed that the leg continues for the most part 
unchanged. 
The shortening and crepitation present in osteo-arthritis of the hip might 
induce a careless observer to mistake this disease for fracture of the neck of 
the femur. But, when the chronic course of the affection is considered, and 
also the absence of any injury to account for the trouble, the error can easily 
be avoided. 
Osteo-arthritis of the shoulder commences much in the same manner as 
that of the hip,-with stiffness, nocturnal pain, and crackling or dry crepita- 
tion. In consequence of the increased synovial accumulation the joint becomes 
swollen, and the movements of the arm become more and more circum- 
scribed, especially that of abduction. The swelling gradually disappears, 
the deltoid muscle shrinks, and the entire shoulder has a wasted appearance. 
In some cases the intra-articular portion of the tendon of the biceps muscle 
is destroyed, and the head of the bone is entirely displaced from the glenoid 
cavity by the bony outgrowths. (Fig. 1024.) 
The tolerance to pressure, the dry crepitation, and the absence of severe 
pain, and of any tendency to suppuration 
or to marked constitutional disturbance, 
are signs that will serve to distinguish 
this disease from any other inflamma- 
tory affections of the shoulder-joint. 
Osteo-arthritis of the teniporo-maxillary 
articulation is peculiar to old persons,- 
rarely seen in the young. It is generally 
bilateral, and induces changes in both 
condyles of the inferior maxillary, and 
in the glenoid cavity of the temporal 
bone; the former becoming altered in 
form, sometimes enlarged, and at other 
times atrophied, or even entirely de- 
stroyed. The cartilages, articular and 
inter-articular, disappear, and the move- 
ments of the jaw are attended with a 
crackling sound. The alteration in the 
form of the articulation may cause great 
deformity of the face and difficulty of 
motion of the jaws, sometimes ending 
in anchylosis. Eburnation is rarely seen 
in the temporo-maxillary joint. 
Osteo-arthritis of the knee-joint may appear at any period of life. The 
synovitis which generally ushers in this disease causes considerable swelling 
of the joint at first. The pain is marked, and is referred generally to the 
internal condyle of the femur or tuberosity of the tibia. Both the limb and 
the joint become deformed. The leg soon changes to the flexed position. 
The tibia is turned outward, causing eversion of the foot, and at the same 
time, through an alteration in the relations of the internal condyle of the 
femur to the tuberosity of the tibia, it allows the knee to become strongly 
inclined inward. The rigidity of the joint increases; any motion of its sur- 
face is accompanied by crackling. The patella is frequently changed in form, 
and may undergo displacement from the surfaces of the femur. Irregular 
Fig. 1024. 
Rheumatoid or osteo-arthritis of the shoulder- 
joint, destroying the bicipital tendon and displacing 
the humerus from the glenoid cavity.-From a 
specimen in the museum of the College of Physi- 
cians, Philadelphia. OSTEO-ARTHRITIS OF SPECIAL JOINTS. 
157 
masses of bone appear about the margin of the articular surfaces of the 
joint; and often, in the cavity of the latter, are seen loose fragments of dis- 
integrated cartilages. 
Pathological Changes.-The heads of the articulating bones-e.g., those 
of the humerus or the femur, or the condyles of the latter-become flattened 
and dwarfed. Bony outgrowths also, which may gradually restrict the normal 
movements of the joint, or even cause, as has been previously stated, a spon- 
taneous luxation, encroach upon or spring from the articulating cavities. 
The change which occurs in the articular cartilage, and which seems to be 
peculiar to this variety of arthritis, is one in which the matrix, instead of 
softening, as in ulcerative inflammation, becomes broken up into fine filaments 
or fibres, giving to the structure a brush-like appearance. In the commence- 
ment of this degeneration the lustre and smoothness of the cartilage are lost, 
and its surfaces become uneven, nodular, and fissured, the clefts extending 
eventually through the entire depth of the structure down to the bone. Co- 
incident with the fibrillation of the intercellular substance, the nuclei of the 
cartilage corpuscles multiply, the cells dividing up and enlarging the cavities 
in the matrix. These new cells attain a larger development than those which 
belong to the granular degeneration of articular cartilage; and, later on in 
the progress of the disease, many of them undergo a fatty transformation. 
Fig. 1025. 
Microscopical appearance of the articular cartilage in rheumatoid arthritis. After Weber. 
Fig. 1025.) This fibrous metamorphosis does not, however, render the car- 
tilage proof against the destructive effects of pressure. The friction to which 
it is subjected between the articular ends of the bones gradually wears it 
down, until it is ground away to a very thin layer and finally is completely 
removed. This new bony formation will become hard, smooth, and polished, 
resembling ivory or porcelain, and hence Cruveilhier applied to the process 
the term eburnation. This dense, polished surface will be found to occupy 
that part of the joint against which is applied the greatest pressure, as the 
upper surface of the acetabulum and the head of the femur, in the coxo- 
femoral articulation; or, where the knee-joint is the subject of the disease, the 158 
DISEASES OF THE JOINTS. 
most convex parts of the condyles of the femur. This, in turn, may be rubbed 
away, and afterwards replaced by the increased activity of the vessels of the 
cancellated tissue, until, by a continuance of the process, a part of the artic- 
ulation may be beveled off, so as to give rise to a marked subluxation. This 
is not unfrequently seen in rheumatic arthritis of the knee. 
In this disease the synovial membrane becomes thickened, and loses much 
of its vascularity; its duplications are thickened, and have a villous ap- 
pearance ; loose fragments of cartilage are found in the cavity of the joint, 
and even in the capsule of the latter plates of bone are deposited. The fluid 
within the articulation is small in quantity, and has a turbid yellow or red- 
dish hue, and the synovia contains less mucin than belongs to the natural 
secretion. The tendons are frequently separated into fragments, sometimes 
destroyed, and their sheaths ossified. 
Treatment.-Unfortunately, there are no remedies at our command pos- 
sessing any curative power over this singular affection. The disease is in- 
curable. The iodide of potassium administered internally is capable of 
affording some relief, and the same may be said of the long-continued use 
of Fowler's solution of arsenic. The local application of the compound 
solution of iodine to the surface of the affected joints may also be used with 
advantage. In a few instances excision has been performed foi* the relief of 
the articulation. 
Strumous Inflammation of the Articular Extremities of the Bones. 
When the articular epiphyses become the seat of inflammation excited by 
constitutional dyscrasia, they undergo very noticeable expansion. The vas- 
cularity of the cancellated structure beneath the lamellae of compact tissue 
is increased, and its cells become expanded and filled with a reddish serum, 
intermingled with fat and medullary tissue. 
The inflammation may be acute or chronic. In either case it constitutes 
a true rarefying osteitis, as the areas inclosed by the osseous lamellae are 
greatly amplified, and their walls become in many instances a series of regu- 
larly radiating columns. The thin, compact layer which incloses the spongy 
tissue of the articular end of the bone also participates in the infiltration, 
and is diminished in thickness. The entire epiphysis becomes softened 
and greasy, and can readily be cut with a knife, or even crushed under the 
pressure of the fingers. If the nutrition of the structure is not too pro- 
foundly disturbed by the inflammatory changes, it is still possible for the 
bone to recover. In this event the restoration is marked by much the same 
changes as those which attend the repair of inflammatory disease in other 
parts of the skeleton, viz., the substitution of a fibrinous and cell transuda- 
tion in the place of the gelatinous one, and its conversion into callus. 
Should the disease advance into the articular lamellae of the bones which 
support the cartilages, the latter will become affected. This is owing to 
the disturbance of the blood-vessels from which they derive their supply 
of nutritive material. The cartilages undergo granular degeneration in 
their totality, or in different parts, or in spots, which, commencing on their 
attached surfaces, advance inward towards the synovial cavity. When once 
this degeneration commences, their connection with the bone begins to loosen, 
and they are detached in fragments from its surface. Nor is the march of 
the inflammatory process arrested at this point; the synovial membrane is 
next attacked, often, indeed, simultaneously with the disease of the carti- 
lages. The inflammation extends to it along the line of the periosteal and 
synovial continuity. Its folds and tufts and other portions, under the free 
transudation and infiltration, are gradually transformed into the pulpy or 
gelatinous granulation tissue, which grows into the fissures and ulcerative 
depressions of the cartilages, and which no doubt gives a new impetus to the 
dissolution of the latter. 
The articular lamella; of the bone, being exposed by the destruction of theii' 
incrusting cartilage, become increasingly vascular, soften, and disintegrate, STRUMOUS ARTHRITIS. 
159 
leaving the cancellated tissue exposed, the granulations from which extend 
into the joint and blend with those of the synovial membrane. 
In other cases epiphyseal inflammation results in suppuration, and the ab- 
scess is discharged through an ulceration in the compact tissue of the bone 
into the joint. The purulent matter in such cases never presents the charac- 
teristics of laudable pus. It is a thin, discolored serum, and contains soft, 
cheesy masses, or it may have a gruel-like consistence and color. Not only 
does suppuration occur in the joint, but, by virtue of the physiological and 
anatomical unity of the articular and periarticular tissues, abscesses form 
in the soft parts external to the joint. These open upon the surface, often 
along sinuous tracts, and continue to discharge their contents as long as the 
process of disorganization is not arrested within the articulation. 
The ligaments, although they may for some time withstand the articular 
inflammation, are eventually involved in the general ruin. In some parts 
they are thickened with a plastic infiltration, at others they are wasted, and 
in both cases they are softened so as to be easily torn. 
Under the exhausting suppuration many patients perish, either worn out 
by hectic or by tubercular disease of the lungs, the spleen, or the mesenteric 
glands. Others again, with singular endurance, resist the ravages of the 
disease, struggling on for years, until at length the necrosed fragments of 
bone are expelled and a spontaneous cure by anchylosis is attained. 
Symptoms.-First stage.-The development of strumous arthritic disease 
is often exceedingly insidious. The trifling inconvenience arising from the 
incipient slight pain and stiffness generally receives a rheumatismal interpre- 
tation. The pains are at first transient, recurring at irregular periods, or 
they manifest a disposition towards periodicity, growing worse at night. The 
patient is able to continue his plays throughout the day, complaining perhaps 
towards evening of some fatigue and uneasiness, possibly of a little swelling 
of the articulation. After the repose of the night these symptoms vanish 
and are forgotten, and with the morning the child is ready to renew the 
active life of yesterday. This may continue for many months, the general 
health remaining unimpaired. It is a happy circumstance for the patient 
when the true nature of the malady is clearly appreciated during this primary 
stage. 
Second stage.-As the disease progresses, the symptoms begin to assume a 
more positive character. The pain increases in severity, and it becomes fixed 
either in the joint affected, or in some part with which the latter has a direct 
nervous communication, as the knee in coxalgia. Not infrequently the pain, 
especially towards evening, is paroxysmal, amounting in some instances to 
agony. The suffering, at the same time, is often intensified by muscular 
spasms of the limb, extorting the wildest expressions of complaint. x Nothing 
causes atrophy of a part more quickly than a painful condition of its nerves, 
and accordingly the nutrition of the affected limb soon becomes disturbed, 
and wasting follows. 
Swelling of the diseased joint likewise takes place, giving rise to a sense 
of fluctuation from the increased synovial and serous secretion. But it is 
so deceptive that, to an unpracticed touch, it may readily appear to be an 
accumulation of pus. The integument covering the joint becomes pale and 
glossy, and although to the hand there is no unusual heat perceptible, the 
thermometer indicates some increase of temperature in the part. As the 
swelling of the joint augments, a change in the position of the limb takes 
place,-a change admitting of the greatest relaxation of the investing liga- 
ments, and, therefore, of the largest swelling with the least tension of the 
articular capsule. The swelling is not limited to the synovial membrane, 
but after some time is increased by an inflammatory transudation into the 
soft parts around the outside of the joint. At this juncture the skin becomes 
increasingly glossy or shining, and is often marked by a configuration of 
veins, the evidence of pressure on the deep-seated trunks into which the 
superficial venous vessels empty. During this time the joint is exceedingly 160 
DISEASES OF THE JOINTS. 
intolerant of motion or of pressure, the patient shrinking from any attempt 
to disturb the affected extremity. 
While these local changes are taking place, the constitution does not fail 
to share a portion of the disturbance. Fever is frequently present; the appe- 
tite is lost, sleepless nights are passed, and the patient loses both strength 
and flesh. 
Third stage.-This stage of the disease is characterized not only by an 
aggravation of the local and general symptoms already detailed, but also by 
the evidences of a more profound disorganization of the joint-structures, e.g., 
suppuration, both intra-articular and extra-articular, abscesses forming at one 
or more points in the vicinity of the joint, and opening upon the surface. 
In consequence of the softening and destruction of the ligaments and carti- 
lages, together with the necrosis of their structure, displacements of the 
articular ends of the bones frequently follow, causing, in many instances, 
troublesome deformities. The hectic symptoms now become more marked, 
as indicated by the evening recurrence of fever, which, passing away in the 
night, leaves the patient covered with perspiration, the exhausting effects of 
which are witnessed in the progressive emaciation and loss of strength which 
follow. 
Notwithstanding this formidable array of symptoms announcing the ravages 
of the disease, there results one compensation, namely, the absence of pain, 
-an effect, no doubt, ascribable to the relief from articular pressure incident 
to the disorganization of the ligaments. 
Though it is common to group the phenomena of strumous arthritis into 
three stages, yet it is proper to state that very often there are no sharply- 
defined boundaries or lines of demarcation separating them one from another. 
The anatomical and pathological conditions which form the basis for such 
a classification may all exist together: in other words, the different compo- 
nents of a joint may be undergoing the different stages of structural change 
at the same time. And, not infrequently, patients pass through the w'hole 
series of these changes-inflammation, effusion, suppuration, and disorgan- 
ization-without experiencing any severe suffering whatever. 
Prognosis.-The prognosis in a case of strumous arthritis will depend on 
several considerations. Among these the most important are the period, at 
which the disease is discovered, the social condition of the patient, the age, 
the intensity of the dyscrasia, and the nature of the exciting cause. 
When the affection is detected in its incipiency, it is possible to shorten 
as well as to diminish the ravages which it inflicts, and, in some instances, 
to arrest it entirely. Even when a case of the disease is undertaken during 
the stage of suppuration, provided every requisite of nursing and treatment 
can be commanded, a favorable issue may be predicted as to the life of the 
patient, though not without permanent stiffness of the joint. It is in cases 
of this class that favorable social surroundings contribute so much to a 
successful result. Among the children of the poor, defective food and 
the absence of numberless comforts conspire to swell the mortality from 
the disease. 
The extraordinary recuperative energies resident in the tissues of young 
children enable them to withstand the ravages of the affection with a greater 
certainty than those of advanced life can hope for. After eighteen or twenty 
the probabilities of recovery are materially lessened. And when the disease 
is developed in mature life, the prognosis is decidedly unfavorable. 
The constitutional tendencies of the child have a most important bearing 
on the final result. Children born into the world of parents both of whom 
had tubercular tendencies possess but little capacity to endure the exhaustion 
attending this form of arthritis. The same may be said of those children 
who, with a favoring organization, have the articular disorder excited by 
some of the diseases common to childhood, such as scarlatina or diphtheria, 
when a few weeks may suffice to destroy the patient. 
Under all circumstances, the progress of the disease is exceedingly slow. STRUMOUS ARTHRITIS. 
161 
In many instances it covers a period of several years. And one of the greatest 
difficulties which the surgeon will have to encounter is the want of a hearty 
co-operation and patient perseverance on the part of the parents or the 
friends of the little sufferer in carrying out the treatment until the end is 
reached. 
Treatment.-In the management of this form of arthritis, the surgeon 
must recognize the fact that in a large proportion of cases the inflammation 
is the sequence of a constitutional condition which will require a considerable 
length of time for its elimination. His treatment must, accordingly, be both 
local and general. 
In instituting local measures, rest and immobility are of the first impor- 
tance in every stage of the disease. These measures can be effectively 
accomplished only by the application of plaster oi' leathei' splints which 
have been accurately moulded to the parts. These splints must include not 
only the diseased joint, but also the rest of the limb. When the inferior 
extremity is the part affected, and the patient is not old enough to use 
crutches, the benefits of rest can be secured only by enforcing uncondition- 
ally the recumbent position. 
Next in importance, if used early, is counter-irritation, applied over the 
articulation. For this purpose blisters may be used, the surgeon repeating 
them from time to time and varying their position at every renewal. In 
young children, blisters not unfrequently cause considerable constitutional 
irritation. When this is the case, they should be laid aside, and resort be 
had to the free use of compound solution of iodine. Pain can often be 
alleviated by placing over the articulation a piece of thin flannel saturated 
with a liniment consisting of laudanum, linimentum saponis, and chloroform. 
The possibility of anchylosis will suggest the propriety of placing the 
joint in a position which, in the event of its becoming stiff, will render the 
limb most useful to the patient,-a matter to be noticed when treating of 
arthritis in special joints. 
The constitutional treatment must be determined by the state of the 
patient's health. In pale, delicate subjects, iron will be required, and it will 
be most advantageously employed by occasionally changing the form in which 
it is administered, at one time using the sesquichloride, and at another the 
iodide. When the appetite fails, quinine or tincture of cinchona will regu- 
late the tone of the stomach. Cod-liver oil, if well digested, is also a valuable 
agent. When the pain is severe, it should be combated by anodynes. 
The diet will demand particular attention. Milk, animal broths, meats, 
yelks of eggs, etc., constitute the most nutritious articles of food ; in addition 
to which the use of wine or some preparation of malt may be allowed. 
When the weather is suitable, the patient should have the benefit of the 
open air, and for this object, when confined to the recumbent position, he 
may be carried out of doors upon the bed. 
When the disease occurs in subjects of a more robust nature, and whose 
appetite and nutrition are not disturbed, internal medicine is of little impor- 
tance. When the pain in the joint is severe, especially if attended by mus- 
cular " starts" or twitchings, extension, when practicable, will afford prompt 
relief. This can be readily applied by means of a weight attached to the 
limb by adhesive plaster and suspended over a pulley, after the manner 
adopted in treating a fracture of the femur. In the event of the muscles 
refusing to submit, tenotomy may be employed. 
The fixation of the joint, as the disease advances, becomes even more 
important than in its incipieney. By some surgeons, cauterization with the 
hot iron, at this time, is believed to possess signal value. Seton-issues and 
blisters have also been advocated; but, while I am not disposed to condemn 
all forms of counter-irritation, I must say that I have never witnessed the 
salutary effects claimed for these remedies at this stage of the affection. 
Indeed, I do not think that any local treatment, except rest, exercises much 
influence over the disease. Something, however, must be done, as the value 
VOL. II.-11 162 
DISEASES OF SPECIAL JOINTS. 
of expectancy in surgery is not appreciated by the lay portion of the com- 
munity. Accordingly, a few strips of vesication three or four inches in 
length may be made over the joint, from time to time, with a solid stick 
of nitrate of silvei*; or the surface may be thoroughly soaked with com- 
pound solution of iodine. If abscesses form external to the articulation, 
and by their extension endanger the integrity of the soft parts, they should 
be opened. 
In neglected cases of arthritis, the limb is often found in a position in 
which, if it were allowed to remain, it would not only be useless but a posi- 
tive incumbrance to the patient. Such malpositions must be promptly cor- 
rected by first administering an anaesthetic, and then bringing the limb to 
its proper place, retaining and securing it there by the use of a splint. When 
the muscles have undergone strong contraction, tenotomy may become neces- 
sary before correction can be effected. 
When suppuration takes place, the joint may be aspirated, after which 
compression with a roller should be applied, and the limb again encased in 
the plaster or leather splint. 
The patient, when sufficiently recovered, should be required to take exer- 
cise in the open air on crutches. When the inflammatory action has passed 
over-leaving, as it usually does, considerable thickening and swelling of the 
soft parts, with more or less rigidity of the joint-local remedies become ex- 
ceedingly important. Stimulating liniments, friction, massage, douches, and 
systematic movements of the articulation comprise the most useful measures 
to remove the inflammatory products and prevent anchylosis. As the limb 
will necessarily remain weak and untrustworthy for a long time, the support 
of a flannel roller around the joint will be a very proper precaution. 
When abscesses form, opening the joint and burrowing in the midst of the 
periarticular tissues, additional care must be observed to have the limb placed 
in a proper position, as it is more than probable that, should the patient 
recover, it will be with an anchylosed joint. 
When exploration discloses necrosed bone, the sinuses should be dilated 
and the diseased osseous tissue gouged out, after which a drainage-tube should 
be introduced through the joint; or a seton of oakum may be inserted,-as 
practiced by Dr. Sayre,-and the sinuses washed out twice a day. 
If the disorganization has been attended with extensive disease of the 
epiphysis, followed by profuse suppuration, and the patient begins to lose 
ground by the induced hectic irritation, excision of the joint offers the only 
prospect of recovery. 
Throughout the progress of the disease, and especially during the period 
of suppuration, the patient's strength must be carefully husbanded and built 
up by suitable food, tonics, and stimulants. 
Sometimes this form of arthritis pursues a very chronic course, the symp- 
toms being subjective, as indicated by absence of acute pain and of muscular 
spasms. In such cases there is little tendency to suppuration, though the 
synovial membrane is greatly changed by the presence of the abundant 
fungous granulation tissue. Under these circumstances, the proper course 
of treatment is to support the articulation with adhesive plasters, over which 
are made to pass a few turns of a soft flannel roller. Then the joint is im- 
mobilized by means of a plaster or a silicate of soda splint. Finally, the 
use of crutches is directed, in order that the patient, while exercising, shall 
not allow the weight of the body to rest upon the foot of the affected limb. 
DISEASES OF SPECIAL JOINTS ARISING FROM CONSTITUTIONAL 
CAUSES. 
Morbus Coxarius (Coxalgia-Hip-Joint Disease). 
Hip-joint disease is a very common form of arthritis, constituting about 
one third of all affections of this class; it is peculiar, for the most part, to 
childhood. Why the hip-joint should be so commonly the subject of arthritis HIP-JOINT DISEASE. 
163 
can only be explained by the strong pressure to which its surfaces are sub- 
jected, and the severe tension of its ligaments, caused by the extensive and 
multiform movements of the joint. The shoulder possesses a similar capacity 
for a great range of motion, but its movements do not necessarily involve 
much pressure between the ends of the bones. Nor is there any inter- 
articular ligament like the ligamentum teres, by the twisting and tension of 
which, injury is inflicted on the articular surfaces of the joint. The knee 
sustains great weight; but its movements are only in two directions, and on 
this account its liability to inflammatory attacks is lessened. 
Boys are more frequently the subjects of hip-joint disease than girls. Of 
100 cases of this affection admitted into the Children's Hospital of Phila- 
delphia, 61 were boys and 39 girls.* Of 837 cases of coxalgia collected from 
different sources, 809 were in children under fifteen years of age. 
The left limb appears to be affected oftener than the right. Out of 112 
cases collected by Mr. Lonsdale, in 65 the disease was situated on the left 
side, and in 47 on the right side. 
It is usual to divide coxalgia into three stages, each being characterized 
by a group of symptoms peculiar to itself. 
First Stage.-The symptoms indicating the commencement of this disease 
are often very obscure. So insidious, indeed, is its approach that in many 
instances serious structural changes have befallen the articulation before the 
existence of the affection has even been suspected. Not unfrequently cox- 
algia is mistaken for rheumatism, and treated accordingly. 
One of the earliest signs which betoken the disease is a slight degree of 
stiffness in the hip, especially in the morning on rising from bed, after a pre- 
vious day of active exercise. This stiffness wears away as the day fares on, 
but in time becomes sufficiently severe to induce the child to abandon tem- 
porarily his youthful sports. It is also accompanied by a slight limp in the 
gait, and frequently by pain referred to the knee. It is this last symptom 
which, in consequence of the knee's remoteness from the hip, often betrays 
the unsuspecting physician into an error of diagnosis. The pain is not un 
frequently periodical, coming on in the evening and disappearing in the 
course of the night. These signs may continue for many weeks, in some 
cases for months, without undergoing any material modification. Sooner 
or later, however, they become more aggravated, and often at this time the 
child is carried to some public institution, or a consultation is requested to 
ascertain the real nature of the malady. 
If the patient is now stripped and examined from behind, while in the 
standing posture, it will be observed that the weight of the body is supported 
on the sound limb; or, if it is transferred to the other, it will be only for a 
few moments. 
The position assumed by the affected limb is peculiar. The thigh is 
slightly flexed on the pelvis, the leg flexed on the thigh, and the foot directed 
forward and a little outward, the entire extremity at the same time being 
somewhat advanced. On comparing the two buttocks, the one on the dis- 
eased side will be discovered to be a little flatter and lower than that on the 
sound side. The gluteo-femoral groove of the affected limb, which, nor- 
mally, so sharply defines the boundary between the nates and the thigh, 
will also be found less distinctly marked than its fellow. (Fig- 1026.) 
As in this disease the muscles about the hip are easily stimulated to resist 
the motions of the joint, their rigidity should be carefully tested. For this 
purpose, let the patient be placed on his back upon a firm, unyielding surface 
like a table or the floor, having the limbs flexed and parallel with each other. 
While thus fixed, let first the sound extremity be straightened, and the knee 
be pressed back until the popliteal space touches the table, which can be 
done without causing the least change in the loins. If now the same ex- 
periment is tried with the affected limb, it will be found that, before the ham 
* Prof. John Ashhurst on Excision of Hip-Joint, Pennsylvania Hospital Reports, 1869, p. 148. 164 
DISEASES OF SPECIAL JOINTS. 
and the table can be brought together, the lumbar portion of the spine will 
become arched u )ward by the tilting of the pelvis, leaving a considerable 
space between the loins and the surface on which they 
previously rested. (Fig. 1027.) Occasionally this symptom 
is absent in the beginning of the disease. 
Another symptom due to muscular rigidity, and of great 
diagnostic value, is the elevation of the pelvis during 
flexion of the affected thigh. This can be ascertained by 
carrying the thigh towards the anterior surface of the ab- 
domen, while the child continues in the recumbent pos- 
ture. As soon as the limb passes beyond a right angle 
with the body, the pelvis will be seen to rise. (Fig. 1028.) 
The sound limb may be flexed until the anterior surface 
of the thigh touches the abdomen, without any percep- 
tible tilting of the pelvis. This same muscular rigidity 
will be discovered in making adduction or abduction of 
the limb, neither of which movements can be carried to 
any extent without the pelvis moving in a like direction. 
Very early in the commencement of the disease, the nutri- 
tion of the limb becomes impaired, inducing a marked 
atrophy, which is the more extraordinary as in many in- 
stances there is little pain and the arthritis is scarcely 
distinguishable. 
Pain will also be experienced when the joint surfaces 
are brought forcibly together. This may be done by 
pressing firmly against the trochanter major while counter- 
pressure is made against the opposite side of the pelvis. 
The experiment may also be made by applying the press- 
ure to the knee or the foot. If tenderness is not dis- 
covered, and it is desirable to make the tests still more 
thorough, this may be done by flexing the leg and forcing 
the femur against the acetabulum, w'hile the limb is placed 
in different positions. 
Second Stage.-The symptoms belonging to this stage are, in the main, 
Fig. 1026. 
Position of the limb 
and appearance of the 
buttock in the first stage 
of coxalgia. 
Fig. 1027. 
Arching of the loins in coxalgia when the posterior surface of the diseased limb is forced in contact with the table 
or floor. 
those of the first stage, except that they are more positive and of greater 
Fig. 1028. 
Pelvis raised in flexing the diseased limb. 
severity. The intra-articular transudation is increased in quantity. The HIP-J01 NT DISEASE. 
165 
effect of this is to cause a greater eversion of the foot, abduction, and a 
fictitious lengthening of the limb. The flattening of the buttock is marked, 
and the gluteo-femoral crease is obliterated. (Fig. 1029.) 
The pain is increased. Sometimes it is referred to the knee, at other times 
to the hip, and it often radiates up and down the 
limb. It is often notably worse at night. Owing 
to the muscular " starts" that ever and anon occur, 
the sleep is disturbed and fitful, the little patient 
waking with a scream. It is in this stage, when 
the symptoms are much aggravated, that the gen- 
eral system sympathizes with the local disorder, as 
is shown by the evening exacerbations of fever 
which set in, attended with a high temperature, 
and followed towards morning by perspiration. The 
appetite is also lost, and the emaciation becomes 
general. 
Explanation of the Symptomatic Phenomena.-The 
pain and stiffness of the articulation, which mark 
the beginning of coxalgia, are due either to inflam- 
mation of the synovial membrane or to osteo- 
epiphysitis. The pain in the knee, w'hich is com- 
monly experienced, has been ascribed by Bonnet to 
the pressure of the internal lateral ligament against 
the condyle of the femur, caused by the malposition 
of the limb. A more rational explanation, and one 
more in accordance with anatomical facts, is sug- 
gested by the nervous communication existing 
between the hip and the knee. The obturator nerve 
supplies the former articulation, the short saphe- 
nous nerve the latter; and these two trunks are 
connected by a communicating branch, which passes 
between the external and deep femoral arteries. 
There are other pains felt, in many instances, 
besides those in the hip and at the knee,-pains which can be explained only 
by reference to the agency of the anterior crural, genito-crural, and sciatic 
nerves. 
In consequence of the synovitis an increased secretion of synovial fluid 
and inflammatory transudation into the articulation take place. This is 
always attended in any joint by a change in the relation of the joint-surfaces, 
-such a change as will afford the largest accommodation to the inflammatory 
product. 
The hip-joint forms no exception to this rule, and, accordingly, we find 
that when its synovial capsule becomes distended with a fluid, that posture 
of the limb is assumed which increases the capacity of the joint, and which 
is the posture characterizing the first and second stages of coxalgia, viz., first 
abduction, and afterwards flexion and external rotation. Bonnet, by a simple 
experiment, demonstrated that this position is largely a mechanical result, 
and his experiment can be easily repeated by any one curious to witness its 
illustration. A hole is bored into the acetabulum from the inner side of 
the pelvis: into this the nozzle of a syringe, with a stop-cock attached, is 
inserted. If now the joint is distended by injecting water through the tube, 
the capsular ligament, not yielding in front, will be noticed to unfold hori- 
zontally, and the thigh will become gradually abducted. Should the capsule 
not give way, and more fluid be injected, the thigh will become flexed, and 
finally rotated in an outward direction. In coxalgia, in addition to the 
mechanical distention by the effusion, the muscles also operate to produce 
the attitude in question. There are consequently two factors concerned in 
causing the postural peculiarity, viz., the intra-articular effusion and muscular 
action. The abduction of the limb is resisted by the adductors; the flexion 
Fig. 1029. 
Position of the limb and appear- 
ance of the buttock in the second 
stage of coxalgia. 166 
DISEASES OF SPECIAL JOINTS. 
of the thigh is opposed by the hamstring muscles, and its outward rotation 
by the obturator internus. So that between the mechanical force of cap- 
sular distention and the vital force of muscular contractility there is a con- 
stant struggle for the mastery. The resultant of this antagonism is a marked 
rigidity of the joint, causing the head of the femur to be drawn tightly against 
the cavity of the acetabulum, which, besides giving the joint an anchylosed 
appearance, constitutes another cause of articular pain. This will be made 
more evident by the relief which is immediately experienced when the foot 
of the affected limb is grasped and the limb extended in the direction of the 
displacement, thus relieving the muscles from the task of fixing the joint. 
Both the muscular rigidity and the pain are less when the disease begins 
in the synovial membrane than when it originates in the bone ; but in either 
case less than would ensue were the motions of the joint left free. 
The apparent lengthening of the affected limb is due to the sinking of the 
pelvis on the diseased side, or rather to its elevation on the sound side, 
in consequence of which the whole weight of the body is placed upon the 
sound limb. 
Third Stage.-This stage of coxalgia is introduced by the signs of great 
structural disorganization and alterations which involve ligaments, cartilages, 
and bones. 
The extension of the inflammation to the capsular ligament causes its 
softening and final rupture, either from ulceration or from extreme distention 
by the intra-articular effusion, allowing its contents to escape into the peri- 
articular tissues. The rupture of the capsule and the discharge of its con- 
tents are followed by a cessation of pain and a change in the position of the 
limb. In some instances the floor of the acetabulum is destroyed by caries, 
even before tbe capsular ligament gives way, when the effusion may pass 
into the surrounding parts. The adductor muscles now regain that con- 
trolling power which they had temporarily lost, or rather which had been 
usurped by the force of articular distention ; and they 
immediately draw the thigh into a state of adduction 
and inversion. 
As the head and neck of the femur, and frequently 
also the cotyloid cavity of the ileum, have, by caries 
and absorption, been measurably destroyed, there will 
be, with the other changes, more or less shortening of 
the limb and some degree of flexion of the thigh. 
This condition, again, is followed by an elevation of 
the pelvis on the diseased side, by which the corre- 
sponding buttock is raised higher than that on the 
sound side and is made to project abnormally. (Fig. 
1030.) Hence the deformity of the third stage is the 
reverse of that noticed in the first and second stages. 
The transition from the second to the third stage is 
variable as regards time. Generally it occurs in a 
gradual manner, especially when the disease begins as 
a synovitis. In this case the ligaments are long ex- 
empted from inflammatory changes, and when they 
do yield it is often over a limited region ; there is, 
therefore, no sudden or free escape of the effusion. 
In some cases the change is the work of a few hours, 
and is the outcome of an arthritis which has been 
inaugurated by a primary inflammation of the epiph- 
yses and cartilages of tbe joint. 
The extravasation consequent upon the rupture of 
the capsular ligament provokes suppuration in the 
soft parts contiguous to the joint. Abscesses form, 
which, having no limiting walls, often by their diffusion inflict serious damage 
on the tissues of the hip and the thigh. The location of these abscesses is 
Fig. 1030. 
Position of the limb in the 
third stage of coxalgia. HIP-JOINT DISEASE. 
167 
not without significance. It is generally determined by anatomical pecu- 
liarities of structure. When it is above Poupart's ligament, it is not im- 
probable that the acetabulum has been perforated; and such perforation is 
rendered certain when the abscess is discharged through the rectum, the 
vagina, the obturator foramen, or the iscbiatic foramen. When the suppu- 
ration finds exit over the nates, or in the line of the gluteo-femoral fold, it 
is an evidence that the acetabulum is involved in the disease. Sinuses which 
form on the outer, anterior, or inner aspect of the thigh usually point to 
caries of the head and neck of the femur alone. There are, however, many 
exceptions to these rules. 
It is not necessary for the formation of abscesses in the soft parts that 
the capsular ligament shall have given way. They are frequently seen when 
there is every reason to believe that such is not the case. They are the result 
of inflammation extending by continuity of tissue to the parts outside of the 
joint; or they arise from disturbances in the nutrition of the soft parts occa- 
sioned either by sympathetic irritation or by a wide-spread congestion of the 
vessels in the neighborhood of the articulation. 
The differential features of the typical stages of coxalgia will be better 
appreciated by placing them in tabular contrast. 
SECOND STAGE. 
The thigh and knee both flexed. 
The limb abducted. 
The limb rotated outward, or toes everted. 
The limb apparently elongated. 
Pelvis lowered on the affected side. 
Pelvis carried forward on the affected side. 
Nates flat and low. 
Pain very severe. 
Abscesses occasional. 
THIRD STAGE. 
Generally the thigh only is flexed. 
The limb adducted. 
The limb rotated inward, or toes inverted. 
The limb really shortened. 
Pelvis elevated. 
Pelvis carried backward. 
Nates round and raised. 
Little or no pain. 
Abscesses common. 
The shortening of the limb which belongs to the third stage varies in 
degree in different cases. It may not exceed one inch, or it may amount, 
in bad cases, to four or five inches. It depends on three conditions: first, 
the destruction, ulceration, and absorption of the head and neck of the femur; 
second, a change in the acetabulum; and, third, luxation of the thigh-bone. 
These will be considered in describing the morbid anatomy of the disease. 
Causes.-The causes of coxalgia are both predisposing and exciting. 
While I do not deny the possibility of hip-joint disease being developed in a 
child of sound constitution, yet such an occurrence is, in my judgment, 
entirely exceptional. I believe that the disease originates in a state of the 
general system, which may be designated as strumous or tubercular. In 
accepting this pathology of the disease, I am consciously at variance with 
some very excellent authorities, though in accord with many others, whose 
opinions merit most respectful consideration. My convictions on this subject, 
however, have been formed from personal observation, quite independent of 
and unbiased by the views of others. It may be said that an argument 
which refers the origin of an arthritis to conditions which have existed, in 
some instances, for one or two generations is very feeble. But I am unable 
to discover any reason why a, priori deductions are not as logical when ap- 
plied to coxalgia as when applied to phthisis pulmonalis or to cancer. The 
fact that a cheesy deposit is not generally found in the epiphyses of the 
articulating bones does not in any way militate against the hypothesis of a 
constitutional origin of the inflammation. Pneumonia and pleuritis are often 
produced by a tubercular dyscrasia before any tubercular deposit occurs in 
the lungs. 
If coxalgia arises solely from external or traumatic violence, why does it 
not yield to treatment like the inflammation resulting from common causes ? 
Why is the pus so different from that characterizing ordinary abscesses, even 
though the patient may in other respects exhibit a healthy appearance? 
How does it come to pass that in one family of children-as I have witnessed 168 
DISEASES OF SPECIAL JOINTS. 
-there may be knee-joint, hip-joint, and spine disease? And the reasoning 
that imputes to this affection a traumatic origin, because the parents can often 
recall some injury which the child at one time received, is fallacious in the 
extreme. Not one lad in a thousand escapes a fall or a sprain. These are 
among the ordinary every-day mishaps of childhood; and, if such are to be 
accepted as the proximate causes of the disease, coxalgia ought to be the 
most common of all affections. 
One of the exciting causes in many instances is, doubtless, some injury 
sustained by the child while engaged in play, e.g., a forcible adduction of the 
limb, straining the round ligament, or a twist or concussion of the articula- 
tion, often, indeed, so slight that unless there had previously existed some 
structural condition favoring inflammation, the trifling violence would have 
been entirely harmless. 
Exposure to cold or to a damp atmosphere not unfrequently excites hip 
disease, much in the same manner as similar agencies give rise to a rheu- 
matic arthritis. Children left in a feeble condition by scarlatina, diphtheria, 
whooping-cough, or measles, are often the subjects of this disease; for the 
vital resistance which the tissues oppose to morbific influences is greatly 
lessened by such disorders. 
Pathology.-As we have but few opportunities of dissecting the hip-joint 
in the early stage of coxalgia, it is difficult to pronounce with certainty what 
particular structure is first affected. Brodie was led by his examinations to 
believe that the cartilages were first attacked,-a conclusion which is set 
aside by more recent researches. An examination made in the advanced 
stage of the disease is calculated to throw but little light on this point. There 
are, however, strong reasons to conclude that the primary seat of arthritis 
is not uniform. It may begin either as a synovitis or an osteitis; and I 
believe it is possible to distinguish between the two. The characteristic signs 
of each may be tabulated as follows: 
SYNOVIAL COXALGIA. 
Lameness often before pain. 
Pain at first slight. 
Marked tenderness when pressure is made over 
the external surface of the joint. 
Muscular rigidity moderate. 
Gentle movements of the joint tolerated. 
Pain not materially increased by crowding the 
joint-surfaces together. 
Pain seldom paroxysmal. 
Change in the position of the limb occurs early. 
OSTEAL COXALGIA. 
Pain before lameness. 
Pain quite severe. 
Little tenderness when such pressure is made. 
Muscular rigidity extreme. 
Movements not tolerated. 
Pain greatly aggravated by such pressure. 
Pain often paroxysmal. 
Change in the position of the limb occurs late. 
When the disease begins as a synovitis excited by a traumatic cause, the 
inflammation commences most 
probably at one of the inser- 
tions of the round ligament,- 
points necessarily exposed to 
injury by violent stretching of 
the latter,-gradually extend- 
ing to the cartilages, and finally 
to the bone. I am in possession 
of an ileum and femur taken 
by Dr. Willard from a lad who 
was suffering from incipient 
coxalgia, and who died from 
tubercular meningitis. The in- 
flammatory redness occupied 
the cartilage a short distance 
round the apetabular and fem- 
oral attachment of the ligamen- 
tum teres, as represented in 
the dark shading in Fig. 1031. Carefully prepared sections of the cartilage 
Fig. 1031. 
Incipient coxalgia. HIP-JOINT DISEASE. 
169 
were made by Dr. Shakespeare, which, under the microscope, exhibited an 
active proliferation of the cartilage cells, greatest on the articular surface, 
notably at the points where the round ligament was attached to the acetab- 
ulum and to the head of the femur, and at the reflection of the synovial 
membrane, but gradually lessening in the direction of the bone. (Figs. 1032, 
1033,1034,1035') 
In severe forms of coxalgia all the components of the articulation undergo 
important structural changes. The synovial membrane, at first thickened by 
Fig. 1032. 
Fig. 1033. 
A, Attachment of the synovial membrane to the cartilage of 
the head of the femur; a, synovial membrane; b, fibrous tissue; 
c, deep portion of the cartilage. 
Infiltration of deep portion of liga- 
mentum teres near acetabulum. 
inflammatory deposits, is ultimately destroyed by ulcerative action. The 
capsular, round, and cotyloid ligaments are doomed to a similar fate. The 
femur suffers the most marked ravages of the disease. The head and neck 
Fig. 1034. 
Fig. 1035. 
Attachment of ligamentum teres to the acetabulum, with 
cartilage softening: a, ligament; b, line of attachment; 
c, cartilage undergoing softening; e, soft area filled with gran- 
ulation tissue; d, space from which some tissue has fallen out. 
Attachment of the ligamentum teres to 
the head of the femur: a, synovial mem- 
brane with infiltration; b, fibrous tissue; 
c, osseous surfaces. 
become carious, and are absorbed to a greater or less extent, presenting 
a dwarfed or stunted appearance (Fig. 1036); or the head may be entirely 170 
DISEASES OF SPECIAL JOINTS. 
detached from the neck of the bone, and lie in the cotyloid cavity. The 
acetabulum, though less frequently involved than the femur, is by no means 
exempt from the destructive inflammation ; sometimes its floor is perforated 
(Fig. 1037) ; at other times it will be seen enlarged or elongated, and shallow; 
Fig. 1037. 
Fig. 1036. 
Changes in thehead and neck of the femur in 
coxalgia.- From a specimen in the author's 
collection. 
Acetabulum enlarged and its floor perforated in coxalgia. The 
head of the femur also in a state of caries. 
and again, through the action of the head of the femur, it will be held strongly 
against its upper surface by muscular spasm, and its upper wall undergoes 
absorption, so that in time the cavity shifts its posi- 
tion, becoming higher, either in an upward or an out- 
ward direction. In such instances it is common to find 
irregular masses of callus deposited about the circum- 
ference of the acetabulum, or the acetabulum filled up 
with callus and united to a misshapen head. (Fig. 
1038.) Should the head of the femur, or, in its absence, 
the neck of the femur, still remain in the cotyloid cavity, 
the thigh-bone will be drawn upward, not only in- 
creasing the shortening, but also causing the trochanter 
major to project very strongly. It is the prominence of 
this portion of the femur, and the attending shortening, 
which give the limb the appearance of being luxated. 
In some cases, where the capsular and round ligaments 
have been destroyed, the head of the bone leaves its 
articulating cavity, and, through the action of the 
muscles, takes a position on the dorsum of the ileum, 
forming for itself a new cavity. This cavity may 
be near the anterior border of the innominate bone 
(Fig. 1039); it may be immediately behind and above 
the position of the old acetabulum (Fig. 1040); or it 
may be on the dorsum of the ileum. (Fig. 1041.) In a few instances the 
head of the femur has been found in the opposite direction, resting on the 
pubic bone, or upon the thyroid membrane. In any event, whether the bone 
remains in the acetabulum or forms for itself a new cavity, anchylosis,- 
fibrous or osseous,-in the large proportion of cases, ultimately occurs. 
Diagnosis.-The diseases most nearly resembling coxalgia and with which 
it is most frequently confounded are the following: dislocation, rheumatism, 
sacro-iliac disease, periostitis, Pott's disease, psoas abscess, psoas and iliac bursitis, 
and diastasis. 
As the limb assumes different attitudes in the different stages of the dis- 
Fig. 1038. 
Head of the femur flattened 
and irregular, and anchylosed 
with the partially obliterated 
acetabulum.-Smith. HIP-JOINT DISEASE. 
171 
ease, the ensuing deformity may imitate either an anterior or a posterior 
Fig. 1040. 
Fig. 1039. 
Fig. 1041. 
Displaced head of the femur, forming 
a new socket between the anterior 
superior and inferior spinous processes. 
Head of the femur displaced upward and 
outward, forming for itself a new socket, 
the old one being changed in form and 
partially obliterated. 
New articulating cavity 
on the dorsum of the 
ileum, fashioned by the 
dwarfed head of the lux- 
ated femur, the normal 
acetabulum havingalmost 
disappeared. 
luxation of the thigh. The distinction will be best illustrated by contrasting 
the phenomena of each as below. 
DISLOCATION OF THE THIGH UPWARD 
AND FORWARD ON THE PUBES. 
Suddenly developed, and the result of traumatic 
violence. 
Shortening of the limb. 
Foot strongly everted. 
Immobility greater. 
Head of the bone felt beneath or under Pou- 
part's ligament. 
Trochanter in front of a perpendicular line 
dropped from the middle of the crest of the 
ilium. 
COXALGIA (First Stage). 
Gradually developed, and not necessarily with 
an injury. 
Elongation of the limb. 
Moderate eversion of the foot. 
Immobility great. 
Head of the femur not felt. 
Trochanter beneath this perpendicular line. 
In luxations into the thyroid foramen, the eversion and elongation of the 
limb closely resemble the same in coxalgia. But the anterior position of the 
head of the bone (which can be recognized by the touch), the history of pre- 
vious violence, the anterior inclination of the body, and the greater disability 
which belong to the dislocation, are sufficiently characteristic to distinguish 
it from hip-joint disease. 
It is, however, with posterior or posterior and superior dislocations that 
coxalgia in its third stage is most frequently confounded. In both affections 
the limbs are shortened and inverted; in both the trochanter is unusually 
prominent; in both the limbs are adducted; and in both the thigh is flexed 
and quite rigid. They may be contrasted thus: 
BACKWARD AND UPWARD LUXATION. 
The work of a moment. 
No previous history of flexion, abduction, and 
eversion. 
Head of femur can often be felt. 
Pelvis unchanged. 
Toes touch the ground, the heel being elevated. 
Spine unchanged. 
COXALGIA {Third Stage). 
Slow in being reached. 
A previous history of these. 
Head of femur so wasted that it cannot be felt 
even when displaced. 
Pelvis oblique or tilted. 
Sole of the foot rests on the ground. 
Lateral flexion of spine to accommodate the 
shortening. 
To the above differential signs between femoral luxations and coxalgia 
may be added the pain experienced at the knee, the frequency of violent 172 
DISEASES OF SPECIAL JOINTS. 
muscular spasms, the relief afforded by extension, and the tender age of the 
patient, all of which belong to hip-joint disease. 
Disease of the sacro-iliac articulation.-This affection in many respects 
imitates coxalgia. The symptoms common to both are lameness, pain when 
the joint-surfaces are pressed together, elongation of the limb, and often the 
presence of abscesses. A careful attention, however, to the following points 
will make the diagnosis clear. 
SACRO-ILIAC DISEASE. 
Patient inclines the body to the opposite side. 
Limb not abducted nor the foot everted. 
Pressure on the trochanter and counter-pressure 
on the tuber ischii cause no pain. 
COXALGIA. 
The inclination of the body is forward. 
Limb everted and abducted in the first and 
second stages. 
Such pressure does cause pain. 
The difference in the two positions is what might be anticipated, as in the 
first affection the object is relief from pressure, while in the second it is the 
accommodation of the intra-articular transudation. 
The counter-pressure gives significance to this test. If not employed, 
pain would be experienced as sensibly in one as in the other affection, inas- 
much as any pressure against the acetabulum would be readily transmitted 
to the sacro-iliac joint. 
Pressure over the posterior borders of the two 
ilii causes pain in the sacro-iliac articulation. 
Elongation of the limb real. 
No change in the gluteo-femoral fold. 
If abscess and sinuses exist, a probe introduced 
into the latter will take a course which terminates 
in the sacro-iliac junction. 
Pain never at the knee. 
Such pressure causes no pain. 
Elongation unreal. 
Partial obliteration of the fold. 
Will take a course towards the hip-joint. 
Pain very frequently at the knee. 
Psoas abscess may be mistaken for coxalgia. The following considerations 
will establish the distinction. 
PSOAS ABSCESS. 
Pain referred to the loins. 
Flexion of the thigh very marked. 
Extension of the limb painful. 
No apparent elongation of the limb. 
Neither abduction nor eversion of the limb 
necessarily present. 
Abscess usually appears in front of the thigh, 
immediately external to the femoral vessels. 
Impulse communicated to abscess in coughing 
or crying. 
Generally appears after puberty. 
Flexion of the thigh can be carried much be- 
yond a right angle with the pelvis without the 
latter moving. 
COXALGIA. 
Pain referred to the hip or knee. 
Flexion moderate. 
Not painful. 
Apparent elongation. 
Abduction and eversion in the first and second 
stages. 
Abscess rarely in this particular position. 
No impulse. 
Appears under puberty. 
Cannot be carried to this extent without eleva- 
tion of the pelvis. 
Pott's disease of the spine has also been confounded with advanced coxalgia ; 
though an error of this kind betrays a great want of careful observation. The 
two affections may be thus distinguished. 
POTT'S DISEASE OF THE SPINE. 
Pain, when present, is in the course of the spine. 
It may be intercostal. 
No obliquity of the pelvis. 
Mobility of the thigh free. 
Pressing the femur against the acetabulum 
painless. 
Antero-posterior curvature sometimes conjoined 
with a rotating distortion of the spine. 
Nates symmetrical. 
Respiration often grunting. 
COXALGIA. 
Pain in neither of these locations, but in the 
hip or the knee. 
Obliquity of the pelvis. 
Mobility much restrained. 
Causes pain. 
Compensating curve lateral. 
Nates asymmetrical. 
Respiration not embarrassed. HIP-JOINT DISEASE. 
173 
Patient stands with equal firmness on both 
limbs. 
Walks with the spine rigidly fixed. 
Squats down in order to lift any object from 
the ground. 
Paralysis of the lower extremities sometimes 
present. 
Rests on the sound limb. 
Can bend or twist the spinal column without 
difficulty or pain. 
Bends down for the same object. 
No paralysis ever present. 
Inflammation of the bursa beneath the tendons of the psoas and iliac mus- 
cles.-This affection also counterfeits hip-disease. The limb is flexed to 
relieve the sac from pressure. There are also lameness and swelling about 
the joint. The swelling, however, is confined in all cases to the inner and 
front part of the articulation, at which position only tenderness from press- 
ure is felt. None is felt, as in coxalgia, when pressure is made over or behind 
the trochanter major. In coxalgia, flexion of the thigh cannot be carried 
beyond a certain point without elevation of the pelvis. In this particular 
form of bursitis, the limb, if cautiously manipulated, can be flexed without 
opposition. 
There are certain conditions which are occasionally met with about the 
great trochanter, such as inflammation of the bursa lying beneath the tendon 
of the gluteus maximus, or a localized periostitis of this part of the bone, which 
in some respects simulate hip-joint disease. There is, however, in these 
affections at no period eversion of the foot; the limb can be easily crossed 
over its fellow and the toes inverted. In the commencement of the disease, 
both the tenderness and the swelling are limited to the region of the tro- 
chanter major,-the slightest pressure over this part being sufficient to cause 
discomfort. 
Separation of the upper epiphysis of the femur.-This injury, though by no 
means common, does occasionally happen, and, as it must necessarily occur 
at an early period of life and be followed by shortening of the limb, it might 
be mistaken for coxalgia. When, however, it is remembered that the short- 
ening in coxalgia is a late event of the disease, and is preceded by abduction 
and eversion, it should not be confounded with the former affection, in which 
the shortening immediately follows the accident, and is attended with ever- 
sion of the foot, the limb being at the same time adducted. Eversion and 
adduction in hip-disease do not go together, but they are consonant with 
the existence of a fracture through the neck of the thigh-bone. For the 
limb, after such an accident, when the patient is in the recumbent position, 
will naturally roll outward, and when in the erect position, from the same 
cause-its own weight-it will fall inward towards the sound extremity. 
Rheumatism.-Frequently have I known coxalgia mistaken for rheumatism 
of the coxo-femoral articulation. And in the incipiency of hip-joint disease 
it is often a matter of some difficulty to establish the distinction. By attend- 
ing to the following considerations the obscurity may be satisfactorily dissi- 
pated. 
RHEUMATISM OF THE HIP-JOINT. 
A heavy ache or soreness occupying the front 
or outer side of the thigh. 
Pain, soreness, and stiffness lessened by exer- 
cise. 
Pelvis elevated on the affected side; conse- 
quently the affected limb is apparently shortened. 
Wasting of the femoral portion of the limb. 
Forcing the joint-surfaces together not painful. 
When the limb is carefully flexed, muscular 
rigidity is not marked. 
Soreness to pressure about the joint. 
COXALGIA. 
Pain at the knee. 
Rather increased.by exercise. 
Pelvis elevated, and of course the limb is ap- 
parently lengthened. 
Wasting of the entire limb. 
Painful. 
Very marked. 
Soreness trifling. 
Prognosis.-In pronouncing upon the future of a case of coxalgia, whether 
as to the fate of the joint or the life of the patient, the surgeon must consider, 
first, the age of the patient. When the disease makes its appearance after 174 
DISEASES OF SPECIAL JOINTS. 
puberty, it is much less manageable than when it occurs in young children, 
and frequently proves fatal. 
Second. When it commences as a synovitis, and in a constitution in which 
the strumous diathesis is not markedly present, the prospect of effecting a 
cure with a useful joint will be encouraging. 
Third. When the inflammation attacks the cartilages and the bones, the 
dangers of the case are greatly increased. For there will probably ensue 
caries, necrosis, and a long period of suppuration, under which should the 
patient not sink from exhaustion, recovery may follow with anchylosis, or 
after excision of the joint. 
Fourth. When the disease is limited to the head and neck of the femur, 
it is less serious than when in the acetabulum, though it is by no means 
free from danger. Yet even in such cases, if treated early, the patient may 
recover without anchylosis. 
Fifth. When, in addition to the involvement of the osseous structures im- 
mediately entering into the formation of the joint, other portions of the pelvic 
bones become implicated, the perils of the case are largely augmented. 
Sixth. Should the disease develop at the termination of a severe attack of 
fever, by which the patient has been much reduced in strength, the proba- 
bilities of recovery will be materially diminished. 
Seventh. In the event of the coexistence of some organic disease of an in- 
ternal organ, such as Bright's disease or phthisis, or of another portion of 
the skeleton, such as caries of the vertebrae, the gravest termination of the 
case will become probable. 
Notwithstanding the dangers which environ the subjects of coxalgia, the 
disease cannot be regarded as a fatal malady. A very large proportion of 
children, if put under early and proper treatment, recover, but in most in- 
stances with more or less deformity, due to anchylosis and shortening of the 
limb. 
It is often impossible, under the most skillful management of hip-joint disease, 
to prevent a certain degree of deformity; but it is of a nature which is entirely 
Fig. 1042. 
Limb anchylosed at nearly a right angle with the pelvis. 
consistent with a good use of the limb, being for the most part limited to short- 
ening with some incurvation of the loins. In neglected or badly-treated cases, 
Fig. 1043. 
Limb anchylosed in the adducted position. 
however, anchylosis is often seen to take place with the extremity in the 
most unfortunate positions. Sometimes the affected limb is strongly adducted HIP-JOINT DISEASE. 
175 
and fixed across the sound one. At other times the thigh is strongly flexed, 
even at a right angle with the pelvis. Figs. 1042 and 1043 are illustrations 
of such distortions. 
Treatment.-At one time, in accordance with certain pathological views, 
the remedies employed in the treatment of coxalgia were entirely of a con- 
stitutional nature, little attention being given to local measures. At the 
present time there are three plans advocated, namely, rest in the horizontal 
position, rest with extension, and extension conjoined with motion. Absolute rest 
for an inflamed joint is sound treatment, both in theory and in practice; 
and I can conceive of no reason wThy the hip-articulation should form any 
exception to this rule. Motion without articular pressure or friction is simply 
impossible, and it is not in the power of man to make it otherwise. Enter- 
taining this view, I am compelled to dissent from the teachings and practice 
of a number of eminent surgeons. I believe that the various mechanical 
appliances designed to combine extension with motion are in most instances 
highly prejudicial, tending to perpetuate inflammation and to favor suppura- 
tion, and thus either to prevent resolution of the arthritis or to delay anchy- 
losis when that termination is inevitable. All the so-called walking splints, 
which allow the weight of the patient to rest on the affected limb, not only 
do not, in my judgment, fulfill the indications required in the treatment of 
coxalgia, but are at variance with all the principles involved in the manage- 
ment of the inflammation. 
The first and paramount consideration is the fixation of the hip-joint; and 
if this is accomplished early, at the commencement of the disease, and en- 
forced with scrupulous particularity, many joints will recover with excel- 
lent motion which under other plans would undergo a destructive osteitis. 
That patients occasionally recover under other modes of treatment I do 
not deny; but the result is not reached in virtue of the plan adopted, but 
in spite of it. What would be thought of a practitioner who should ad- 
minister drastic cathartics in a case of gastritis or enteritis? Quietude is as 
necessary to an inflamed joint as to an inflamed intestine; functional act- 
ivity and vascular tension go together. Even if it were possible to establish 
motion in a joint without friction, there would still remain the fact that the 
stimulus of the motion alone must necessarily serve to attract an increased 
amount of blood to the articulation, and consequently to intensify the inflam- 
mation already present, the removal of which is so necessary to the preserva- 
tion of the integrity of the articular structures. Only when I have been 
able to carry out enforced fixation have I succeeded in obtaining the best 
results in coxalgia. The value of articular rest was understood by Physick, 
who, to effect this indication, confined the patient to the recumbent position, 
and employed a carved splint accurately fitted to the hip-joint. 
The dressing which I employ consists of a few plain and plaster rollers, and 
a splint like that used by Mr. Thomas, of Liverpool, made of thin sheet-steel 
one inch wide and three-sixteenths of an inch thick. This splint is made 
long enough to extend from the middle of the posterior surface of the leg to 
the middle of the trunk. It is bent so as to rest close up against the tuber 
ischii, beneath the nates, and on it are placed two semicircular strips of strap- 
iron, the one on the thigh part of the iron, and the other on the leg part; 
these may be slid up or down at pleasure. Two short segments of metal are 
also connected to the upper end of the splint, and are designed to embrace 
half the circumference of the body. (Fig. 1044.) A shoe with a cork sole 
two and a half or three inches high, designed for the foot of the sound limb, 
is also required. 
The patient must be made to stand on the sound limb, with a book, a 
brick, or some other body placed beneath the foot of the affected limb and 
sufficiently high to correct the obliquity of the pelvis and the inclination of 
the spine. 
Next place the splint along the posterior surface of the leg, the thigh, the 
buttock, and the back, and bend it with a wrench (Fig. 1045) so as to make 176 
DISEASES OF SPECIAL JOINTS. 
it conform exactly to the outline of these parts. This may be easily effected, 
as the metal is made sufficiently flexible for the purpose. This done, the 
surgeon takes a plain roller and applies 
it around the limb, beginning at the 
middle of the leg, and continuing it up to 
the groin, from which point it is passed 
to the body, and ended by a few circular 
turns beginning about the crests of the 
ilii and terminating at the lower angle 
of the scapula. For this roller (which 
is merely designed to keep the plaster 
from coming in contact with the skin) 
there may be substituted a single-legged 
woolen drawer, woven out of very thin 
material. 
The next step consists in wetting one 
of the plaster rollers in a basin of water, 
and, after squeezing out the redundant 
liquid, applying the bandage around the 
limb at these points, viz., at the middle 
of the leg, at the knee, and around the 
thigh a short distance below the buttock, 
after which the roller is made to encircle 
the body as high as the inferior angle of 
the scapula, taking care not to touch the 
crests of the ilii, which, unless this precaution is observed, are liable to 
become excoriated by the plaster. 
The splint is now to be placed in position on the posterior aspect of the 
limb, pelvis, and back, fitting accurately over and under the buttock, with its 
branches embracing the leg, the thigh, and the body (Fig. 1046), and is to 
be secured by a second and third plaster roller, following the order and course 
of the first, that is to say, at the middle of the leg, at the knee, and around 
the body. 
In a few minutes the dressing begins to stiffen, when the child may be laid 
in the recumbent position for one or two hours, in order to wait the comple- 
tion of the hardening process. When this has taken place, the bandage may 
be slit along the anterior part of the limb and along the sound side of the body, 
to which portions straps and buckles can be sewed in order to hold it in place, 
or it may be allowed to remain undivided. 
Sometimes the splint shows a tendency to slip down, and to obviate this it 
is well to have four stout linen loops-two in front and two behind-attached 
to the upper border of that part of the apparatus which surrounds the body. 
To these loops can be fastened strips of muslin passing over the shoulders 
and answering the purpose of suspenders to the splint. 
Lastly, the cork-soled shoe being placed on the foot of the sound limb, the 
little patient can be allowed to go about on crutches. (Fig. 1047.) By this 
arrangement the affected extremity will be raised so far from the ground that 
it will be in no danger of being used, either for support or in walking. 
The child when too young to use crutches must be placed in the recumbent 
position, on a firm mattress, and in fine weather may be taken in the open 
air, by placing the bed on wheels, or carrying it on a stretcher. 
There is another way in which the splint can be held in position, and which 
answers the purpose equally well with that in which the plaster is used, 
namely, by leather pads and buckles attached where the segments of strap- 
iron are placed on the leg and body portions of the splint. (Fig. 1048.) In 
this manner it can be worn over a pair of thin woven drawers and be firmly 
secured in place. The suspenders should be added in order to prevent the 
instrument from slipping down. 
When the limb is found in a state of flexion, and before anchylosis has 
Fig. 1044. 
Fig. 1045. 
Hip-joint splint. 
The wrench. HIP-JOINT DISEASE. 
177 
occurred, its posture can be corrected by administering ether, and gently 
bringing it into the proper position, after which the immovable dressing can 
Fig. 1046. 
Fig. 1047. 
Fig. 1048. 
- 
Splint placed in position. 
Pressing applied. 
Splint prepared for buck- 
ling on to the limb. 
be applied. Another plan, and one which I prefer, as it is followed by no 
suffering or injury to the joint, is to make the correction gradually. For this 
purpose increasing weights must be suspended from the extremity by means 
of adhesive plasters, cord, and pulley, applied as in fracture of the thigh. 
(Fig. 1049.) Before commencing the traction, a support of pillows should 
be placed beneath the limb and adapted to its contracted, flexed position. 
The extension must always be made in the line of the deformity. As the 
corrective process progresses, the pillows can be lowered or altered, until 
the limb is finally brought into a line with the body. 
Mr. Thomas, of Liverpool, uses in the treatment of coxalgia an appliance 
in many respects like the one which has been described, which he secures 
in position by plain rollers alone. I do not think, however, that the joint 
can be so thoroughly fixed by this plan as when the plaster bandages are 
employed. 
In rectifying any malposition of the limb, Mr. Thomas adjusts his splint to 
the extremity in its abnormal posture, and, after the sensibility subsides, as 
it soon will do after the articular immobilization, he gradually corrects the 
deformity by altering the angle of the apparatus from time to time. 
Whenever abscesses exist, the pus should be early removed by the aspi- 
VOL. II.-12 178 
DISEASES OF SPECIAL JOINTS. 
rator. Should sinuses be present, traps must be cut in the plaster-if the 
latter is used to secure the splint-corresponding to the fistulous openings. 
Fig. 1049. 
Gradual extension of the limb in hip-joint disease in the line of deformity. 
It will not be necessary to disturb the dressing for two or three months, 
unless the patient complains of constant pain and discomfort,-symptoms 
which indicate that the splint has not been accurately adapted to the inequal- 
ities of the limb,-in which event it should at once be removed and re-applied 
with greater care. 
If the splint with the leather pads, straps, and buckles is employed, its 
removal, alteration of shape, and re-application require only a few minutes. 
If the treatment is commenced in the incipicncy of the disease and is 
faithfully enforced, we may reasonably hope, in very many instances, to 
arrest the arthritis, secure its resolution, and preserve the functions of the 
articulation in the course of four or five months. Such a result will be in- 
dicated by the absence of muscular rigidity and the ability to move the joint 
freely without pain. 
Nevertheless, it would be highly improper, even under such circumstances, 
to throw aside the apparatus and to abandon longer treatment. Such a 
course would most probably be followed by the reappearance of the inflamma- 
tion in a form more intractable than that assumed at the outset of the disease. 
On the contrary, the treatment should be maintained with the utmost care 
for at least one year, when, if the mobility and painlessness of the joint con- 
tinue, the patient may venture, with great caution, to use the limb for a 
short time every day, unincumbered by any mechanical appliance, until fully 
assured that the recovery is permanent; or, to insure greater safety to the 
joint, a splint may be worn for some time like the one represented in Fig. 
1050, which fits up against the tuber ischii and possesses a perineal band. 
When this desirable result is not obtained, the next best result to be sought 
for is anchylosis. To effect this may require several years, and during this 
time the necessity for continuing the immovable apparatus will be imperative. 
As a part of the local treatment for coxalgia, some surgeons attach much 
importance to the use of blisters, or to the application of the actual cautery 
over the outer side of the articulation. I have never seen any benefit follow 
the employment of either, and have long since abandoned their use. 
Dr. Hutchison, of Brooklyn, New York, discards all splints in the treat- 
ment of coxalgia, using only the high shoe and the crutches, believing that 
the muscles are quite sufficient to secure the required immobility of the articu- 
lation. But it must be remembered that to give a joint absolute rest it is 
necessary that the muscles as well as the bones should be in a state of 
quietude. The rigidity of the muscles must necessarily invite a large amount 
of blood to the parts, and increase the inflammation. 
Constitutional treatment is of little value when the child's appetite is good, 
when the rest is not disturbed, and the nutrition of the body but little im- HIP-JOINT DISEASE. 
179 
paired. When, however, abscesses accompanied by free suppuration exist, 
it will be necessary to provide for the drain on the blood-vessel system by 
more than usual attention to the diet of the 
patient. The diet should be one supplying 
the largest amount of plastic materials of 
nutrition, as milk, meats, eggs, and broths. 
The different preparations of iron and of 
cod-liver oil are also of great value. And, in 
order to maintain the appetite and to in- 
vigorate the digestion, the child should be 
Fig. 1051. 
Fig. 1050. 
Author's splint, sometimes worn fora few months after the 
cure of the joint has been effected. Front and back view. 
Davis's splint.-1, band for counter- 
extension; 2, swivel; 3, sliding joint; 
4, buckle; 5, key with handle ; 6, screw; 
7, button. 
much in the open air, on the crutches, or, when incapable of using them, 
he should be hauled about on a mattress mounted upon wheels. 
Other modes of treatment.-It w'ould be unjust to many American surgeons 
not to notice the ingenious plans which have been from time to time devised 
with a view to permit motion and at the same time to avoid joint pressure,- 
which is not only irreconcilable with my theory of the treatment of hip-disease, 
but is, I believe, an impossibility. Doubtless the reluctance with which 
parents consent to the rest treatment for their children suffering from coxalgia 
has had a great influence in stimulating the invention of different forms of 
walking apparatus. On account of this parental obstinacy and unreasonable- 
ness, the surgeon, even where his judgment disapproves, is sometimes com- 
pelled to compromise by adopting a splint of this kind, or otherwise to 
abandon the little patient, incapable of choosing for itself, either to the 
merciless experiments of charlatans or to utter neglect. 
The idea of combining extension with motion in hip-joint disease originated 
with Dr. Davis, of New York. To accomplish this he devised the apparatus 
shown in Fig. 1051. It consists of an external steel splint, extending from 180 
DISEASES OF SPECIAL JOINTS. 
a short distance above the ankle to the crest of the ilium, and at the upper 
extremity of which is a swivel for attaching a counter-extending perineal 
band, partly elastic and partly inelastic. At the lower end is a screw, having 
a button on the outer side, near its free extremity, in which to fasten a 
strip of webbing, and which can be lengthened by a key at pleasure for the 
purpose of making extension. At the upper third of this splint is a sliding 
joint, by which the appliance can be lengthened or shortened, thus answering 
for limbs of different length; and at its lower third is attached a buckle 
for securing the band which surrounds the knee. 
In applying the Davis splint, two longitudinal strips of adhesive plaster 
one inch and a half wide should be placed along the outer and inner aspects of 
the diseased limb, the former extending from the great trochanter to about one 
inch below the external malleolus, and the latter extending from the perineum 
to about the same distance below the internal malleolus. The lower end of 
each of these plasters is to be turned upward to the extent of an inch or an 
inch and a half, the adhesive surfaces being applied together. To the folded 
ends are next sewed pieces of strong, unyielding webbing, each nine or ten 
inches long. To render the longitudinal strips more secure, two others, of 
less width, should be carried about the thigh and the leg in a spiral manner 
(Fig. 1052), and the limb covered in by a spiral reversed roller. 
If the thigh of the patient is flexed, the first object will be to bring the 
limb, very gradually, into the straight position. 
To accomplish this, the leg must be extended in 
a line with the femur, and both supported on 
pillows, with the body sufficiently raised to relax 
the psoas and iliacus internus muscles. In this 
posture extension is to be made by tying together 
the ends of the webbing, secured to the lower 
extremities of the adhesive strips, and attaching 
to the loop a cord, which runs over a pulley at 
the foot of the bed, and from which is suspended 
a weight. Gradually the plane on which the limb 
rests must be lowered, as also the body of the 
patient. The extremity is brought into a straight 
line with the trunk,-usually the work of several 
days. 
When this has been accomplished, the time has 
arrived for applying the splint, which is done as 
follows. The weight being detached, the steel bar 
is laid along the external surface of the limb over 
the roller; the counter-extending band is carried 
over the perineum and buckled into the ends of 
the swivel, and the webbing sewed to the end of 
the external adhesive strip, being disconnected 
from its fellow, is brought over the extremity of 
the screw (attached to the lower part of the 
splint) and made fast to the button on its outer 
surface. With the "handle" the screw is next 
turned, which, by lengthening the splint, pro- 
duces both extension and counter-extension. 
(Figs. 1053, 1054.) In order to fix the knee, the 
cap is now applied, the ends of which are passed 
through the buckle on the outside of the steel 
bar. During the treatment the splint is removed 
at night, and the extension maintained by the 
pulley and weight, as in the first instance. As 
soon as the extreme sensibility disappears, the patient is allowed to walk 
about. 
The splint of Professor Lewis Sayre, acting on the principle of that of 
Fig. 1052. HIP-JOINT DISEASE. 
181 
Davis, is modified in such a manner that, for walking, extension is made 
from the thigh, and counter-extension from the groin, the appliance not ex- 
tending below the knee. 
The apparatus consists of 
a steel bar made up of 
two sections, one running 
within the other, and long 
enough to extend from 
the crest of the ilium to 
a point two inches above 
the lower end of the 
femur. This bar, by means 
of a key and a ratchet, 
Fig. 1053. 
Fig. 1054. 
Fig. 1055. 
Davis's splint applied. Side view. 
Front view, without 
the roller. 
Prof. Sayre's hip-joint splint. 
can be lengthened or shortened at pleasure. At its upper end, and con- 
nected with it by a ball-and-socket joint, is a well-padded pelvic band, to 
pass round a portion of the body, to which one or two perineal bands are 
attached for counter-extension. At the lower end of the bar is attached 
a rectangular branch, designed to include a part of the inner side of the 
thigh ; and at the lower end of both the outer and inner pieces of metal are 
rollers, over which run the tabs attached to the ends of the adhesive plas- 
ter used for extension. Immediately above the rollers are placed buckles 
designed to receive the forementioned tabs. (Fig. 1055.) As this apparatus 
is only to be worn during the day while the patient is walking about, it 
is supplemented by another arrangement designed to keep up extension 
at night. This must be applied previous to that used for retaining the splint 
in place. 
Two strips of adhesive plaster, two or three inches wide, and long enough 
to extend from the malleoli to a point four or five inches above the knee, 
are placed on the outer and inner sides of the leg and thigh, each having a 
piece of webbing, three or four inches long, sewed to the lower end. These 
longitudinal plasters are next secured to the leg (leaving out a part of the 
tabs) by a roller commencing at the foot and carried up above the knee. A 
portion of the upper end of each longitudinal plaster strip should be turned 
down over the roller, and be covered in by a few of its descending turns,- 
a procedure which makes the dressing more secure. A piece of board, three 182 
DISEASES OF SPECIAL JOINTS. 
inches long and one inch and a half wide, is next to be secured between the 
two tabs of webbing, forming a stirrup below the foot, to which is attached a 
cord for suspending the weight which is to make extension. 
To apply the apparatus for walking, first cut two fan-shaped pieces of ad- 
hesive plaster long enough to extend one from the perineum and the other 
from the great trochanter to the knee, the broad portion of each being suf- 
ficiently wide to support and to embrace the semi-circumference of the thigh. 
They should be slit into several strips, that they may be applied with greater 
accuracy to the limb. To the narrow ends of these fan-shaped plasters pieces 
of strong, inelastic linen webbing, about four inches long, are sewed, the 
breadth of which must conform to the rollers on the lower ends of the 
branches of the metal 
splint. (Fig. 1056.) The 
plasters are now to be 
placed upon the thigh, 
the tabs of webbing 
reaching to points on a 
level with the lower ex- 
tremity of the patella, 
where, with the excep- 
tion of two inches and a 
Fig. 1057. 
Fig. 1058. 
Fig. 1056. 
Fan-sbaped adhesive plasters with 
tabs attached. 
Fan-shaped plasters applied and fastened with the roller. 
half of their lower ends, they are secured by a roller. This is afterwards 
carried up the thigh, reversing the alternate strips of plaster, and covering 
them in with the bandage (Figs. 1057, 1058), until the perineum is reached, 
when the roller may be finished by descending turns. This done, the thigh 
is now prepared to receive the splint, the shaft of which must be shortened 
as much as possible. 
The pelvic cross-bar, attached to the upper end of the instrument, is now 
placed immediately below the crest of the ilium, and the lower end of each 
branch of the appliance is attached to the limb by bringing the tabs of web- 
bing over the rollers at their extremities and fastening them into the buckles, 
which are a short distance above. Next, buckle the ends of the perineal 
band in place, observing to interpose between it and the groin a piece of old 
linen to prevent excoriation. 
Extension and counter-extension are next made by the key and ratchet. 
This apparatus, which is worn only during the day, must not be removed 
until the bed-extension has been applied at night. 
As this mechanism does not in any way control the movements of the 
knee, it must necessarily allow of a greater range of motion at the hip than HIP-JOINT DISEASE. 
183 
that permitted by the apparatus of Davis; and this motion is altogether at 
variance with my notions of treating arthritis 
Professor Sayre, in some cases, employs a 
long splint, consisting of two bars, one of 
which is received within the other, and ex- 
tending from the crest of the ilium to the 
sole of the foot, underneath which it is fast- 
ened to the shoe. At its upper extremity 
is an iron girdle, and to this are attached 
two perineal bands, one for the sound and 
the other for the affected limb. There is 
also a knee-pad. (Fig- 1059.) 
A number of other walking splints are in 
use, as those of Hutchison, Bauer, Andrew, 
S.W. Gross, Pancoast, and Barwell: but they 
are all constructed on very much the same 
principle, and with a view to permit motion 
of the joint without articular pressure or 
friction,-an impossible task. 
Conditions requiring Operative Meas- 
ures.-There are conditions following ar- 
thritis of the hip-joint which demand sur- 
gical operations, as vicious anchylosis and 
extensive necrosis. In consequence of neglect, 
or the absence of any treatment whatever, 
the head of the femur may become united 
to the acetabulum or its vicinity, while the 
limb is in a position rendering it not only 
useless for motion or support, but a posi- 
tive hindrance to both. In some instances 
the thigh is flexed on the pelvis; in others, it is adducted and crossed over in 
front of the sound limb. The anchylosis may be fibrous or osseous, but in 
either case is capable of correction. 
Fibrous anchylosis.-In addition to the adhesion of the head of the femur 
to the acetabulum or its borders, the muscles will often be found greatly con- 
tracted. To remedy this, after etherization, tenotomy becomes necessary, 
requiring, in many instances, the division of the tendinous origins of the 
adductors, gracilis, tensor vaginse femoris, and rectus femoris muscles, and 
not unfrequently, in addition, portions of the fascia lata of the thigh. After 
all opposition from these sources has been overcome, a moderate degree of 
force will enable the surgeon to bring the limb into a proper line with the 
body, in which position it must be maintained either by extension with 
weights, or by bandaging the extremity to a long external splint, well padded, 
to prevent excoriations. 
Bony anchylosis.-When the limb becomes solidly fixed in an evil position, 
by bony adhesion taking place between the innominatum and the head of the 
femur, nothing short of severing the bone will correct the deformity. The 
first operation of this kind was devised and executed by Dr. John Rhea Bar- 
ton, of Philadelphia, in 1826. Professor Sayre, of New York, in performing 
this operation, removed a block of bone from the femur above the trochanter 
minor by a double incision; one part of which-the lower-was made con- 
vex across the bone; and the other-the upper-was made concave. The 
object was to fashion the ends of the divided femur in a manner which would 
favor the formation of a pseudo-ball-and-socket joint. The objection to the 
above plans is the necessity of making an open wound, with its attendant 
dangers,-an evil which is entirely obviated by the procedure of Mr. Adams, 
of London, who divides subcutaneously the neck of the femur instead of that 
part of the bone below the trochanter major. 
For the execution of the last-named operation, there are required a long, 
Fig. 1059. 
Sayre's modification of Taylor's splint. 184 
DISEASES OF SPECIAL JOINTS. 
narrow, and sharp-pointed bistoury and a peculiarly-shaped saw eight inches 
in length, the teeth occupying about one inch and a half of the extremity 
of the blade. (See Figs. 1615, 1016, p. 145.) 
Adams's operation.-The patient being etherized, and placed on the sound 
side or on the back, as may be most convenient, the long knife is entered 
immediately above the great trochanter, and carried directly on until the 
point comes in contact with the neck of the bone. Then it must be with- 
drawn, and the end of the saw entered, and passed along the same tract 
flatwise. When the bone is reached, the blunt point of the instrument must 
be raised, and carried over the front of the femur, and with its cutting edge 
turned upon the latter, when, by short back-and-forth movements, the bone 
can be divided. The separation once effected, the saw must be withdrawn, 
the small wound closed by a strip of adhesive plaster, and the limb at once 
brought into the proper position, and secured after the manner directed in 
fibrous anchylosis. 
Mr. Maunder, of London, employs a narrow chisel with which he divides 
the femur. But the saw is to be preferred, its use being free from the risk 
of comminution of the bone. 
Excision.-Cases will occur in which anchylosis fails,-a condition, I fear, 
not unfrequently invited by those plans of treatment which allow motion in 
the joint. The inflammation of the articular ends of the bone results in 
necrosis. The head of the femur, eroded and wasted, may become entirely 
detached from its neck, and fragments or sequestra of bone, separated from 
the acetabulum, may lie loose in the joint. Under these circumstances, the 
suppuration and hectic symptoms which attend so extensive an articular 
disorganization will rapidly exhaust the vital resources of the child, and 
render it necessary to remove all causes of irritation by excising the joint. 
Before resorting to so radical a measure, the surgeon should inform him- 
self thoroughly as to the extent of the disease and the general condition of 
the child. It must have been observed by any practitioner who has had 
much to do with coxalgia that patients make excellent recoveries by the 
operation of natural processes alone, notwithstanding the presence of articu- 
lar suppuration and necrosis. The disintegrated particles of bone are ex- 
truded along with the discharges; after which anchylosis follows. 
Whenever, therefore, an excision is contemplated, the patient should be 
placed under an anaesthetic, and the joint carefully explored by digital ex- 
amination, the finger being carried through one or more of the sinuses, which 
may, for this purpose, be dilated, or, if too small, incised. In this way only 
can a correct opinion be formed as to the extent of articular disorganization. 
The probe may also be used to reach points too remote for the finger to 
touch, and thus aid in communicating the desired information. If, upon 
making such an examination, the head of the femur, or its remains, is found 
adherent to the acetabulum or to the ilium, the suppuration is gradually 
diminishing, and the health of the child is improving, it will be wise to ab- 
stain from any operation, and patiently to wait for further developments. 
Should loose fragments of bone be discovered, they must be extracted by the 
forceps through one of the fistulous openings, and the cavity of the joint 
must be frequently washed out with disinfecting lotions, such as the solution 
of permanganate of potash, nitrate of lead, carbolated water, or dilute tinc- 
ture of iodine. A free drainage should be established by the use of the rubber 
tube, or by a rope of twisted oakum, so justly esteemed by Sayre. If, in 
connection with these measures, the immobilization of the hip is maintained 
and the general health is supported, we may entertain a sanguine hope that 
the case will recover by anchylosis. 
The conditions which, as a rule, do not require excision, I may formulate as 
follows: 
First. The operation is never allowable where no evidence of necrosis exists. 
Second. As long as the disease is limited chiefly to the synovial membrane, 
without disorganization of cartilages or bone, the knife should be withheld. HIP-JOINT DISEASE. 
185 
Third. The operation is improper in cases in which anchylosis is progress- 
ing and the general health of the patient is not failing. 
Fourth. Suppuration in itself constitutes no indication for excision. For it 
may exist both within and without the joint without the bone being involved. 
Fifth. Partial necrosis, either of the head of the femur or of the ace- 
tabulum, does not necessarily demand the operation, unless the child is 
losing flesh, strength, and appetite, and presents the signs of increasing joint- 
disorganization. 
Cases for excision.-When, however, the head and the neck of the femur 
are found to be necrosed, with or without a similar state of the acetabulum, 
the propriety of excision cannot be questioned; and notably so if, in addi- 
tion, the patient's health is steadily failing under suppuration and constitu- 
tional irritation. 
There are cases, again, where the indications for operation are much less 
pronounced than the above, but which are, nevertheless, proper subjects 
for excision. For example, when, upon examination, the surgeon discovers 
no extensive bone destruction,-none incompatible with a cure by natural 
processes, provided the constitutional resources of the patient are sufficient to 
endure a long and tedious process of suppuration,-but yet there are observed 
a slowly-progressing but steady emaciation, loss of strength, and other signs 
of pysemic irritation, under such circumstances, and with the uncertainty 
of the child being able to endure the exhaustion incident to a long period of 
inflammatory changes necessary to exfoliation or anchylosis, it will be better 
to cut out the diseased structure and substitute a healthy for an unhealthy 
sore. 
In turning to statistical data for some guiding light upon this important 
subject, a rather formidable mortuary record is encountered. Of 111 excisions 
of the hip-joint collected by Dr. Hodges, 56 recovered, 53 died, and in 2 cases 
the result was unknown. The collection made by Dr. Good, of Paris, em- 
braces 112 cases, with 52 recoveries and 60 deaths. Mr. Holmes has reported 
19 cases, with 8 recoveries, though only 3 were complete recoveries. Pro- 
fessor Sayre reports 39 cases, with 20 deaths, 5 of which, however, cannot be 
referred, either directly or indirectly, to the operation. The tables of Dr. 
Ashhurst comprise 470 cases of hip-joint excisions, 234 of which recovered, 
192 died, and in 44 the result was not ascertained, or a mortality of 45.1 
per cent. Of this number, 177 were examples of complete, and 241 of in- 
complete or partial excisions; in 52 the extent of operation is not stated. 
The determined results for the complete excisions were 90 recoveries, 77 
deaths, and 10 unknown, or a death-rate of 46.1 per cent.; for the partial 
excisions, 124 recoveries, 97 deaths, and 20 undetermined, or a mortality of 
43.9 per cent.; and for those the extent of which was not mentioned, the 
recoveries were 20, the deaths 18, and the uncertain 14, or a mortality of 
47.4 per cent.; the average mortality for all the excisions being 45.1 per 
cent. If we sum up all these data, it appears that the percentage of re- 
covery after excision is about 45. Any deductions based on the above 
statistics as unfavorable to excision will be entirely fallacious. They do 
not present the subject in a just light. For in a large number of patients 
the operation was undertaken only as a last resort, and when the ravages of 
the disease and the attendant constitutional exhaustion had necessarily dimin- 
ished the prospect of recovery. Had early operations been practiced in these 
cases, an entirely different result might have been obtained on the side of 
recovery. 
The age of the patient forms an important factor in the result of hip-joint 
excisions. Thus, in a total of 195 ascertained terminations of the operation 
executed for coxalgia, three-fourths (109) of the recoveries occurred in chil- 
dren under fifteen years of age, the mortality steadily rising to 75 per cent, 
at thirty years of age. Bryant, in an analysis of Hodges's and Good's tables, 
reaches a similar conclusion. 
When the excision is made, it should include not only the head and neck 186 
DISEASES OF SPECIAL JOINTS. 
of the femur, but also the trochanter major, as the prominence and irregu- 
larity of the latter cause a degree of irritation which is unfavorable to the 
work of repair. 
When the acetabulum is involved in the disease, it will be necessary, by 
means of the gouge and chisel, to remove such portions of it as may be 
found necrosed,-a procedure which does not appear to add materially to 
the mortality of the disease. The danger which attends the excision of this 
part of the innominate bone arises from the possibility of intra-pelvic puru- 
lent infiltration. As long, however, as no damage is done to the strong 
expansion of the pelvic fascia, which lies within the bone, the risk from this 
cause is not great. 
When an excision of the articular extremity of the femur is done for the 
disease under consideration, the bone should as much as possible be denuded 
of its periosteum, thereby preserving, to some extent at least, the conditions 
requisite for a reproduction of new bone. 
In a few instances* the complete ablation of the limb at the hip-joint has 
been substituted for excision. But the cases justifying this procedure are 
certainly very rare. 
With the exception of the hip, the knee-joint is more frequently attacked 
by disease than any other joint of the body, and its extent and complexity 
seem to confer a peculiar obstinacy upon its inflammatory affections. Chil- 
dren under fourteen or fifteen years of age are, ordinarily, the subjects of this 
form of arthritis. 
Causes.-The exciting causes of knee-joint disease are cold, and external 
violence operating on a peculiar constitutional condition or organization. 
Symptoms.-Among the earliest signs of the disease are tenderness when 
pressure is made over the inner side of the knee-joint, and a slight limp in 
the limb of the affected side. A careful inspection of the articulation will 
usually detect an alteration in its form. The condyles of the femur, and, 
more rarely, the head of the tibia, are found to be enlarged. The depressions 
which normally exist on either side of the patella are less marked than those 
of the sound limb, one of the earliest indications of intra-articular effusion. 
The tenderness, which is chiefly confined to the inner aspect of the joint, 
is most probably caused by irritation of the saphenous nerve, the branches 
of which are largely distributed over this part of the articulation. If an 
attempt is made to extend the knee fully, it fails, and occasions pain. Not- 
withstanding the uneasiness, the slight lameness, and the dragging of the 
limb, the patient will continue to walk and run, perhaps, for several months. 
At length the enlargement of the joint increases, until all its characteristic 
outlines disappear, and it presents a uniformly round swelling; the leg becomes 
flexed and more painful, and the suffering periodical, until finally the child 
can no longer walk. Should the disease not be arrested, the skin over the 
joint becomes white and glossy and marked by arborescent veins. The thigh 
wastes; the condyles of the femur enlarge; and the ligaments yield, allowing 
the hamstring muscles to displace the head of the tibia backward, or to rotate 
it outward. (Fig. 1060.) The future drift of the disease will tend in one of 
two directions. In certain cases the swelling becomes more prominent over a 
portion of the joint, with redness of the skin and fluctuation, and in a short 
time the part opens, discharging a quantity of thin, curdy pus. Othei' abscesses 
may form at different places about the articulation, and open in like manner, 
until the joint becomes riddled with sinuses. The local irritation also reacts 
upon the general system, giving rise to evening exacerbations of fever; the 
appetite fails; the child loses flesh and strength, and he may be still further 
prostrated by diarrhoea. After the suppuration takes place, and the abscesses 
open, the pain is generally relieved, or it wholly disappears. Even under 
Knee-Joint Disease, or "White Swelling." 
* Ashhurst's Surgery, 2d edition, p. 617. KNEE-JOINT DISEASE. 
187 
these unfavorable circumstances the suppuration sometimes subsides, the 
fistulous tracts gradually contract and close up, the joint becomes more 
firmly fixed, and the patient recovers with angular 
anchylosis of the knee and a withered limb. In 
other instances, the fluctuating synovial swelling 
becomes more firm and elastic, and often reduced 
in size. This alteration indicates a change in the 
inflammatory products within the joint, and is 
accompanied with plastic thickening of the syno- 
vial membrane and the production of fungoid 
granulations, which penetrate the erosions in the 
cartilages, and, after the destruction of the latter, 
may unite with granulations from the bones and 
produce anchylosis. A case of this kind may 
progress, from beginning to end, with very little 
suppuration, or oven with none at all. 
As in coxalgia, so in knee-joint disease, the in- 
flammation may begin either as an articular os- 
teitis or as a synovitis. Generally it is not difficult 
to determine the distinction. When originating 
in the bones, the expansion of the latter will be 
early noticed by comparing the two limbs. The 
general swelling which follows this indicates the 
spread of the disease to the synovial membrane, 
causing effusion. 
When commencing as a synovitis, intra-artic- 
ular effusion, with general swelling and fluctua- 
tion, will precede any change in the form of the 
bones, should the latter become affected. Or, if 
the disease assumes the fungoid or pulpy condi- 
tion, there will be neither enlargement of the 
articular extremity of the bones nor fluctuating 
swelling, but the joint will be enlarged, will have 
a doughy feel, its normal configuration will be 
obliterated, and all the recesses of the articula- 
tion will be filled with a soft, semi-solid granulation tissue. 
Prognosis.-The termination of knee-joint disease will depend upon its 
early recognition, and upon the social condition and general health of the 
patient. When detected in its incipiency, and the child is so situated as to 
command careful nursing and judicious surgical aid, a cure by resolution 
may be anticipated; or, in the event of failure in this, anchylosis may result, 
and the limb be preserved. Should the disease not be arrested in the early 
stage, it will run, generally, a very slow, chronic course. This is what might 
be expected from the great extent of the osseous articular surfaces, synovial 
membrane, and ligaments, and from the presence of the semilunar cartilages, 
all of which have to be modified or destroyed before consolidation can be 
effected. 
Treatment.-The great indications in the treatment of knee-joint disease 
are to suspend the function of the articulation by placing it in a state of 
absolute and unconditional rest, and to correct the constitutional condition 
which underlies the morbid process. For the first five or six weeks the rest 
should not only be articular, but general, the patient being confined to bed. 
If the leg is flexed, it must be restored to the straight position with as little 
delay as is consistent w'ith the safety of the joint; and this object is best 
attained by a gradual and not by a sudden force. Tbe muscles which, during 
the flexion of the limb, had become shortened, cannot be suddenly lengthened 
without great resistance, the effect of which must be to bring strongly 
together the articular surfaces of the joint, already too sensitive to pressure. 
Tbe correction in position should, therefore, be conducted in a very gentle 
Fig. 1060. 
Knee-joint disease, with displacement. 188 
DISEASES OF SPECIAL JOINTS. 
manner, by placing the limb over an inclined plane of pillows, or by swinging 
it from a cradle and suspending gradually increased weights from the leg, by 
means of adhesive plasters as in hip-joint disease. (See Fig. 1049, p. 178.) 
As the straightening process goes on, the plane or supporting bands can be 
lowered until the rectification is complete. This work may require only a 
few days, or it may extend over two or three weeks. Tenotomy is rarely 
demanded in these cases of knee-joint disease early treated. 
As soon as the rectification has been effected, a plaster splint must be im- 
mediately applied, extending from three inches above the ankle to the middle 
of the thigh. Should any swelling ensue, the dressing can be split up in 
front, or it may be applied in the first instance by recurrent turns of a 
plaster bandage, leaving a little of the anterior surface of the limb uncovered; 
by a roller bandage the plaster splint can be held securely in position. Gen- 
erally, however, soon after the splint has been applied, the swelling begins 
to subside, when it will be necessary to re-apply the plaster dressing so as to 
preserve an accurate support of the joint. 
As soon as a noticeable amelioration of the local symptoms takes place, the 
patient may be allowed to rise from the bed, but under no circumstances to 
place the weight of the body upon the foot of the affected limb. To prevent 
this, and at the same time to allow exercise in the open air, a high-soled 
cork shoe, or a metal support under an ordinary shoe, must be worn on the 
foot of the sound limb, and the patient be compelled to use crutches as in 
coxalgia. 
If the general health is impaired, it will be proper to administer cod-liver 
oil and the different preparations of iron and iodine. The diet should be 
nutritious, but unstimulating. 
If the joint becomes distended with a sero-synovial or a purulent accumula- 
tion, it should be aspirated. This can be done with entire safety; it may be 
repeated from time to time, if necessary, and it will conduce not only to the 
relief of pain, but to the resolution of the inflammation. Prof. Sayre employs 
an apparatus in these diseases of the knee-joint which is designed to combine 
articular rest with extension. The instrument consists of two steel collars, 
one inch wide, and long enough to encircle the one the thigh and the other 
the leg below the joint. These collars admit of being opened, and then closed 
and locked by a hinge and a clasp, and are connected with each other by two 
rods, which can be lengthened or 
shortened by a rack and pinion, 
worked by a key. (Fig. 1061.) This 
apparatus is secured to the limb by 
means of adhesive plasters placed 
longitudinally around the thigh, from 
the lower end of it almost to the 
groin, and in the same manner around 
the leg, from the head of the tibia to 
a little above the ankle. These plas- 
ters are bound to the leg and thigh 
by a roller, leaving about two inches 
of each uncovered. (Fig. 1062.) The 
instrument is next slipped around the 
thigh and the leg, and, after being 
adjusted, is fixed in position by turn- 
ing the ends of the plaster (left un- 
covered by the roller) over the bands 
and securing them by the turn of an- 
other bandage. (Fig. 1063.) 
By turning the screws connected 
with the lateral rods of the instrument, 
extension and counter-extension are made on the knee until all sense of the 
pain which is experienced by standing on the foot of the affected side is 
Fig. 1062. 
Fig. 1061. 
Sayre's apparatus for 
the knee. 
Adhesive plasters applied 
to the thigh and leg for 
securing the extension ap- 
paratus to the limb. KNEE-JOINT DISEASE. 
189 
removed. After this is done, a third roller is carried from the foot to the 
knee, with a view to prevent swelling of the leg. 
The objection to this ingenious contrivance is the difficulty of keeping the 
tension of the instrument uniform when the 
patient passes into the care of the parents; 
and unless this end be secured the immobility 
of the joint is not assured. Without the ful- 
fillment of this indication, I hold, no articula- 
tion in a state of inflammation is in the best 
condition for recovery. When, however, the 
case can be kept under professional super- 
vision, the apparatus may answer a very good 
purpose. 
Thomas, of Liverpool, employs an appa- 
ratus which, by transferring the weight of 
the body to the ischium and perineum, re- 
lieves the knee-joint from pressure when the 
patient is standing or walking. This instru- 
ment consists of two parallel metallic rods, 
connected by a piece of sacking or leather, 
with a foot-piece and a metallic patten at 
their lower extremities, and also a ring, well 
padded, and attached, at an angle of fifty- 
three degrees, to the upper ends of the rods, 
and having a buckle in front and behind for the attachment 
of a strap. (Fig. 1064.) 
This apparatus is applied by slipping the ring over the 
limb and carrying it up along with the lateral rods to the 
perineum. The foot rests on the foot-piece, and the splint 
is bound to the limb by two flannel rollers,-the one applied 
above and the othei' below the knee. A patten is also screwed 
to the shoe of the sound limb. To keep the perineal ring 
in place, a strap is connected to it behind, and, after being 
carried over the opposite shoulder, is fastened to its anterior 
part. 
When the arthritis has resulted in a disorganization of 
the joint, in which the synovial membrane has become 
thickened by plastic deposits, the cartilages necrosed, and 
the articular ends of the bones carious, with sinuses through 
the soft parts, there are four courses of practice open to the 
surgeon. These are expectancy, laying open the joint and 
cauterizing its cavity, amputation, and excision. 
With regard to the expectant plan, it may be said that as 
long as the general health of the patient is not seriously 
endangered by excessive suppuration or by hectic irritation, 
there is hope that a spontaneous cure may follow. It is 
difficult to place limitations to the curative power of natural processes. 
Accordingly, the surgeon may be content for a time with applying the 
plaster splint, in which traps are cut corresponding to the positions of the 
sinuses, and through which the discharges can escape, and the dressing can 
be applied without disturbing the joint. When these sinuses communicate 
with the cavity of the joint-a condition which can be ascertained by the 
use of the probe-and are discharging freely, the articulation should be 
cleared by daily injections of permanganate of potash, nitrate of lead, or 
carbolated water. Once or twice a week, after the use of these liquids, 
the compound solution of iodine, half the officinal strength, may be injected, 
or a solution of iodoform (three grains to the ounce). Under this treatment 
the exfoliation of the bone is hastened, the cartilages disintegrate and are 
ejected, and healthy granulations may spring up and solidify the joint. 
Fig. 1063. 
Fig. 1064. 
Sayre's apparatus 
applied. 
Thomas's knee-joint 
splint. DISEASES OF SPECIAL JOINTS. 
Should no favorable result ensue upon this course, and the suppuration in- 
crease, or the caries continue to extend, it will be better to lay the joint freely 
open on either side, giving the freest possible vent to all accumulations, and, 
after picking away any loose fragments of bone or cartilage, to pass a Chas- 
saignac tube or a rope of oakum through the openings from side to side to 
secure ample drainage, and at the same time to enable the surgeon to treat 
the cavity of the articulation with the washes already prescribed. 
Mr. Hayward,* after cleansing the joint with a mop of lint, packed its 
cavity with lint saturated with dilute sulphuric acid one-third the officinal 
strength, thus hastening the separation of the diseased tissues by sloughing 
and exciting healthy granulations, by which'alone anchylosis can be secured. 
Although this plan is represented as effectual in the few cases in which it has 
been adopted, yet so radical a method should be accepted with caution, until 
a larger experience shall have tested its safety and determined its true value. 
The leg must be preserved in the extended position, as the anchylosis, when 
it occurs, is more secure in this than in the slightly flexed posture. 
When the caries and necrosis of the articular ends of the bones are exten- 
sive and progressing, and the general health of the patient is steadily failing 
under the suppuration and the general irritation, notwithstanding that the 
freest drainage has been established, there remains the choice between am- 
putation and excision. Excision is always to be preferred for children, and 
amputation for adults. 
190 
Chronic arthritis of the ankle-joint is next in order of frequency to that 
of the knee. The inflammation may extend to the articulations of the tarsus, 
or the converse of this may be realized. 
Causes.-The disease is excited, usually, by some contusion or twist of the 
joint. But it frequently arises without any known cause. Exposure to damp- 
ness and cold may call into existence the inflammation, 
especially when there exists an organization favoring its 
development. 
When due to a traumatic cause, the inflammation, I 
believe, often begins in the ligaments. These structures 
are peculiarly exposed to injury in consequence of the 
peculiar conformation of the articulation and of the 
strain to which they arc subjected, when, owing to a 
malposition of the foot, the weight of the body is brought 
to bear upon their fibres. 
Symptoms.-This disease frequently comes on in a 
very insidious manner,-manifested only by a little sore- 
ness and stiffness in the joint after the exercise of the 
day. These symptoms, after a short period of rest, 
subside, and the patient is able to resume the use of 
the limb; but they return, and gradually increase in 
severity, and are attended with swelling. The swelling 
first makes its appearance at those portions of the artic- 
ulation where the least resistance is encountered,- 
namely, in front of and between the malleoli and the 
extensor tendons of the foot. Later, the depressions on 
either side of the tendo Achillis and behind the malle- 
oli are obliterated by the swelling, the leg becomes 
wasted, and the foot assumes the extended position, 
often hanging in a distorted, helpless, and expressionless 
manner, with the toes pointing downward. (Fig. 1065.) 
Flexion and extension are resisted, and, when attempted, 
cause uneasiness and pain. If the ligaments have participated in the disease, 
the lateral mobility of the joint is increased; and if abscesses have formed 
Ankle-Joint Disease. 
Fig. 1065. 
Ankle-joint disease. 
* Chirurgical Society's Transactions, vol. vi. ANKLE-JOINT DISEASE. 
191 
and opened, a probe can be passed along the fistulous tracts into the joint, 
and may, perhaps, be brought into contact with dead or denuded bone. 
When the enlargement is due to pulpy degeneration or fungous granula- 
tions, there will probably be neither abscesses nor sinuses present. In this 
condition all the characteristic features of the joint will be obliterated, the 
swelling will have a semi-elastic and doughy feel, and the skin will present 
a purple discoloration; or it may retain its natural color. In well-marked 
cases of this type, even when the cartilages have been eroded and the bones 
denuded, it is difficult to obtain any crepitus or grating, as the fungosities 
spread over the articular surfaces in a manner to prevent it. 
When the disease begins as an osteitis or an epiphysitis, there will be 
noticed a marked enlargement or expansion of the bone, even before any 
material amount of swelling takes place. 
Diagnosis.-The morbid conditions with which disease of the ankle-joint 
may be confounded are inflammatory transudation of the sheaths of the 
tendons which pass to the foot behind the malleoli, and caries of the astrag- 
alus and the os calcis. 
In the former of these two last-named affections the tenderness and swell- 
ing are confined to the course of these tendons,-i.e., to those portions of the 
joint behind the external and internal malleolus : while in arthritis of the 
ankle-joint the swelling is first observed in front of the articulation. Ex- 
tension and flexion are also more painful in the former than in the latter 
disease. 
In caries of the astragalus the swelling is at some distance anterior to the 
tibio-tarsal joint, on the dorsal aspect of the foot; and when the disease is 
located in the calcaneum, the swelling is over the heel. The sinuses which 
attend caries of these bones are usually situated over the parts affected. 
Those present in ankle-joint disease are closer to the malleoli. 
As in all these inflammatory conditions the movements of the tibio-tarsal 
articulation are, by the reflex irritation of the muscles about the joint, dimin- 
ished, it will be desirable, when any doubt remains as to the diagnosis, to 
administer an anaesthetic, in which case, if the articulation is free from dis- 
ease, it will be found to move freely and without any grating or other 
abnormal sounds. 
Prognosis.-As in other joints, so in that of the ankle, when the arthritis 
is early detected and subjected to proper treatment, the disease may be re- 
solved and the function of the joint preserved intact. When, however, the 
case has been neglected, and allowed to go on until the cartilages and liga- 
ments have become necrosed, it may terminate in a cure by anchylosis, 
though too often the disorganization demands either excision or amputation. 
Treatment.-Suspension of all motion and of all undue articular pressure 
is an indispensable condition in the treatment of chronic arthritis of an ankle- 
joint. 
The foot should be placed at a right angle with the leg, and so maintained 
by a plaster roller, commencing at the foot, extending over the ankle, and 
continued up almost to the knee, the parts having been previously covered 
with a bandage or a very thin, neatly-fitting stocking. A high-soled shoe 
must next be placed on the sound foot, and the patient put on crutches. If 
the child is too young to use crutches, it should be kept in bed, or it can be 
carried about in the open air, and, when circumstances permit, it may ride 
out in a carriage. In cases of adults it is not necessary to use the high shoe, 
as the patient can be instructed to allow no weight to rest on the foot of 
the diseased limb. The great object is, in addition to fixing the joint, to pre- 
vent all forcible contact of the articular surfaces of the bones. As the swelling 
subsides, it will be necessary to renew the splint in order to follow up accu- 
rately the receding enlargement. For, should this be neglected, the joint 
will lie loose in the plaster shell, and consequently will not be entirely im- 
mobilized. 
When abscesses exist, it will be necessary to cut traps in the splint, through 192 
DISEASES OF SPECIAL JOINTS. 
which the discharges can escape, and by means of which dressings can be 
applied. 
When the joint becomes disorganized by suppuration and caries, there is 
little prospect that the case can be brought to a favorable termination with- 
out an operation. And this should not be too long delayed; for, if not con- 
trolled, the disease may extend beyond the limits of the tibio-astragaloid 
joint, and invade the bones of the tarsus, committing such structural ravages 
as to necessitate amputation of the foot. In anticipation of these conse- 
quences, it is better to remove the diseased bone from the articulation by 
gouging or by excision. 
The operation of gouging is effected by enlarging one or more of the fistu- 
lous tracts, and carrying the openings through into the joint with a gouge or 
a scraper, the cutting parts of which should be somewhat dull, in order that 
no damage may be done to vessels during the operation. (Fig. 1066.) With 
these instruments the diseased portions of bone can be detached without 
destroying the investing periosteum. After this part of the operation, the 
debris should be washed out by injecting the joint with a stream of lukewarm 
carbolated water. 
Fig. 10G6. 
Gouge and scraper. 
A very expeditious mode of removing the diseased articular surfaces is by 
means of a burr (Fig. 1067) driven by a surgical engine. A free incision is 
made in order to expose the interior of the joint and to admit of the intro- 
duction of the burr, by which the bone can be cut away with the greatest 
rapidity and ease. 
Fig. 1067. 
When the diseased bone has been removed, by whatever plan, and the 
debris washed out with the injection, a free drainage must next be established, 
either by the rubber tubes, or, better, by a twisted cord or rope of oakum,- 
a material which has been very justly extolled by Professor Sayre. 
If there exists an opening on both sides of the articulation, the oakum 
should be carried directly across the joint from side to side. If the disease 
is limited to one side, it may be entered and again brought out at another 
opening on the same aspect of the joint. 
As these setons become saturated by the discharges, it is necessary that 
they should be removed every two or three days, and others made to take 
their place. This is readily done by twisting a second piece of oakum with 
the seton already in place; as the latter is withdrawn, the fresh piece is 
passed into the opening. 
After the introduction of the seton, the foot should be placed at a right 
angle with the leg, and a plaster splint be applied, so as to secure the most 
perfect immobility of the joint. The appareil must have openings or traps 
Burr. ANKLE-JOINT DISEASE. 
193 
cut in it answering to the extremities of the seton, and through which the 
dressings can be made without disturbing the articulation. As the swelling 
about the ankle diminishes, it will be necessary to renew the plaster dressing 
or to remove it, and, after filling up the irregularities about the joint with 
oakum, to apply a roller and replace the splint. As soon as healthy granu- 
lations form,-which may be known by the diminution of the suppuration 
and the contraction of the sinuses,-the seton may be diminished in size, and 
finally dispensed with entirely, and the patient be allowed to move about on 
crutches, wearing a high-soled shoe on his sound foot. With the diminu- 
tion of the suppuration and the contraction of the sinuses comes the neces- 
sity for gentle and cautious passive movements, with the view of securing a 
movable joint, as it by no means follows that the disease of a joint treated 
in this manner must necessarily terminate in anchylosis. Accordingly, flex- 
ion and extension may be made, very carefully at first, and only for a few 
moments; and if the joint does not resent the manipulation by becoming 
painful, hot, and swollen, or by an increase of pus, these movements may be 
renewed two days later. If they are still well tolerated, greater liberty may 
be taken in continuing the treatment. 
Long after all internal manifestations of disease have disappeared, there 
will remain some inflammatory induration or thickening of the soft parts 
about the joint. This can be gradually got rid of by kneading, rubbing, the 
cold or the warm douche, and compression, either by adhesive plasters or by 
a flannel roller. The gum-elastic bandage may be used for the same purpose. 
Great caution will be required in resuming the use of the limb, that inflam- 
mation be not again excited. Indeed, several months should pass before the 
weight of the body is allowed to rest, in walking, on the affected limb. 
Professor Sayre employs an apparatus by which, in the early stage of ankle- 
joint disease, before serious structural changes have occurred, it is thought 
the articular surfaces may be relieved from pressure during walking. 
This instrument consists of a steel collar to surround the leg, a foot-piece 
to'fit the sole of the foot, and two rods, each having a male and female screw, 
and connected with the band and 
the foot-piece,-the anterior rod by 
a hinge and stirrup. (Fig. 1068.) 
The limb is prepared for the appa- 
ratus by first placing longitudinally 
around the leg strips of adhesive 
plaster long enough to extend from 
the ankle to the tubercle of the 
tibia. These strips are additionally 
secured by covering them in with 
a roller, leaving about three inches 
of theii' upper extremities exposed. 
The band of the instrument is 
opened, slipped around the leg, and 
clasped, and the free ends of the 
adhesive strips turned over the col- 
lar and fixed by a roller. The foot at the same time is placed upon the 
foot-piece and made fast by adhesive plasters and a bandage. With a key 
the screws in the two rods are next turned, increasing the extension until 
the patient realizes the required support. (Fig. 1069.) 
Fig. 1068. 
Fig. 1069. 
Sayre's splint for the ankle. 
Apparatus applied. 
Arthritis of the Calcaneo-Astragaloid and Astragalo-Scaphoid Joints. 
This disease is often overlooked. It affects both children and young adults. 
It may have a strumous, a syphilitic, or a rheumatic origin. The exciting 
causes are concussion of the joint surfaces by falling upon the feet, and con- 
stant walking. 
Symptoms.-Pain is caused by forcible abduction or adduction of the affected 
VOL. II.-13 194 
DISEASES OF SPECIAL JOINTS. 
foot, or by pressing firmly upon the dorsum of the foot in front of the mal- 
leoli. The foot is markedly everted, and rigid, owing to the fact that the 
peroneal muscles are in a state of fixed contraction, and this gives an undue 
prominence to the internal ankle. So firmly is this malposition maintained 
that the surgeon may easily suppose the existence of anchylosis,-a condition 
which, in long-neglected cases, really does present itself. This had taken 
place in a young woman recently under my care, who had suffered from 
repeated attacks of the disease. 
Treatment.-When early recognized, the affection is one which generally 
yields to treatment. Rest alone, in the recumbent position, for a few days, 
will resolve the spasm of the peroneal muscles and allow the foot to assume 
its natural position. As soon as this spontaneous reduction takes place, a 
plaster splint should be applied to the toot, ankle, and leg, and the patient 
placed upon crutches for eight or ten weeks, until the inflammatory state of 
the joints has disappeared. 
If there is reason to believe that a rheumatic or syphilitic element is pres- 
ent, the use of iodide of potassium will be indicated; and when the constitu- 
tional manifestations of struma can be detected, cod-liver oil and iodide of 
iron should be administered. 
Arthritis of the Tarso-Metatarsal Articulations. 
Inflammation in these joints is not so often observed as in those which 
have already been considered. 
The swelling which attends the disease may extend up as high as the ankle 
and render the diagnosis somewhat uncertain. By fixing, however, the 
ankle-joint, or by grasping the foot in front of the malleoli and holding it 
firmly with one hand while the tarso-metatarsal articulations are pressed 
together or put upon the strain with the other hand, the tenderness or pain 
consequent upon such tests may be referred to the proper joints. But it 
must be noted that, if neglected, after a short time the inflammation passes 
by continuity of structure to the othei- joints above. 
Treatment.-Immobility is as important in the treatment of inflamma- 
tory disease of the tarso-metatarsal joints as in that of the other joints of the 
foot. Hence the necessity for covering the parts with a thin, neatly-fitting 
stocking, and placing over this a plaster roller extending from the toes 
to five or six inches above the ankle, and for rigidly interdicting any use of 
the foot. 
A thorough inquiry should be instituted in every case of the disease, with 
a view to ascertain the existence of any dyscrasia which may have been 
influential in causing the inflammation. In the event of any such being 
recognized, constitutional treatment for its correction should be resorted to. 
The danger, in all instances of tarsal arthritis, consists in the tendency of 
the disease to pass beyond the limits of the joint and to become an osteitis. 
After two or three weeks of general rest, the patient may be allowed to 
exercise on crutches. 
Arthritis of the Metatarso-Phalangeal Articulations. 
Though any one of these joints may be attacked by inflammation, that of 
the great toe suffers most frequently. 
The disease may arise from gout, rheumatism, scrofula, or syphilis, and- 
more frequently than other tarsal affections-from traumatic causes alone. 
The synovial membranes of the metatarso-phalangeal joints being independ- 
ent of one another, there is little or no tendency in the inflammation of one 
to extend to another. The same may be said of the phalangeal articulations. 
If the gouty form of this disease prevails, there will be a tendency to a re- 
currence of the inflammation, and, after a time, to the deposit of the urate 
of soda, both within and without the joint, and eventually great distortion 
of the toes. ARTHRITIS OF THE OCCIPITO-ATLOID ARTICULATION. 
195 
Symptoms. - Upon the surgeon's grasping the metatarsal bone of the 
affected toe w'ith one hand and its proximal phalanx with the fingers of the 
other, and pressing the articular surfaces together, or forcing the phalanx 
in different directions, the patient will complain of pain and tenderness. In 
some instances crepitus may be distinguished. 
Treatment.-The treatment is the same as in arthritis of other tarsal 
joints, namely, fixation and rest by means of the plaster roller, which should 
include the foot, ankle, and lower part of the leg, in order to secure quiet to 
the flexor and extensor muscles of the great toe. When several of the toes 
are affected, and after the inflammation has been subdued by rest and immo- 
bility, though showing a tendency to recur on the use of the foot, advantage 
will be derived from wearing a shoe with a thick inside sole of cork ex- 
tending only to the middle of the metatarsus. By this contrivance, in 
wmlking, the toes will be relieved from all pressure. 
When the disease is gouty in its origin, it will be most expeditiously com- 
bated by a mercurial purge, follow'ed by iodide of potassium conjoined with 
belladonna and colcbicum. 
Arthritis of the Occipito-Atloid and Atlo-Axoid Articulations. 
Although disease of these joints does not materially differ from tuberculosis 
of other portions of the spine, yet, in consequence of the form and function of 
the atlas and axis, and the danger to life which attends inflammatory changes 
in their structure, it is proper to treat of them separately from other pieces 
of the spinal column. The extent of the movements-especially that of 
rotation-to which the head can be carried in virtue of the connections which 
exist between the atlas and the axis and the odontoid process and occipital 
bone, must necessarily allow a great strain on the ligamentous apparatus of 
the parts, and constitute an exciting cause of inflammation in the articula- 
tions oi' in their ligaments, particularly when the general conditions are 
present which predispose to disease. Whether the inflammatory process 
commences as a synovitis or as an osteitis, it usually proves to be very in- 
tractable in its course, destroying the ligaments to such an extent that the 
occipital bone may become displaced from the atlas, or, what is more common, 
the atlas may be displaced from the axis. The displacement is usually for- 
ward, and it may be followed by sudden death, in consequence of pressure 
on the upper part of the spinal cord. In cases of a chronic nature the dis- 
placement may occur so gradually, and be so associated with inflammatory 
changes, by which the diseased vertebrae, the ligaments, and even the mem- 
branes of the cord become blended together in a confused mass of connective 
tissue and callus, that, notwithstanding the space appropriated to the medulla 
spinalis within the ring of the atlas may be encroached upon, the pressure 
does not prove sufficient to suspend the functions of the cord, and the patient 
may-not only live, but recover without paralysis, though exhibiting con- 
siderable deformity. 
Symptoms.-The disease commences with stiffness in the muscles of the 
neck, accompanied by dull, deep-seated pain and swelling in the back of the 
neck. The suffering is much increased by motion, which the patient is careful 
to avoid; and to prevent it when sitting up or moving about, he takes pains to 
steady the head by placing one hand under the chin and the other over the 
occiput; or, if compelled to direct the attention to one side or the other, he 
will turn the whole body instead of the head. Pressure on top of the head 
aggravates the pain. As the disease advances, the swelling extends as high 
up as the insertion of the muscles on the semicircular ridges of the occipital 
bone, and across from one mastoid bone to the other. The muscles become 
hard and rigid, owing to the inflammatory infiltration, the surface pitting on 
firm pressure. 
When the forward displacement of the head commences, the deformity is 
more apparent; the spinous process of the axis, which normally is out of 196 
DISEASES OF SPECIAL JOINTS. 
sight and touch, becomes visible ; the chin appears unusually advanced ; deg- 
lutition is difficult and painful; pains extend to the shoulders and down the 
arms; swelling appears in the posterior wall of the pharynx, obstructing the 
posterior nares, spreading to the fauces, and causing difficulty of breathing, 
or even the protrusion of the tongue from the mouth. 
Abscesses may open into the pharynx, or on the back of the neck, through 
the cavities of which fragments of necrosed bones may be discharged. When 
the spinal cord becomes compressed, either by inflammatory products or by 
the gliding forward of the head with the atlas, paralysis of the upper and 
afterwards of the lower extremities follows. Or asphyxia may suddenly 
occur from interruption of the respiratory process, consequent upon pressure 
on the medulla. 
Prognosis.-This affection, under any circumstances, must be regarded as 
fraught with great danger to the life of the patient. The gravity increases 
with the age of the patient. As long as no signs of paralysis are present, 
there will be reason to hope for recovery. But even the presence of paralysis 
is not incompatible with recovery, provided the medulla remains free from 
injury. 
When the patient does recover, it is by anchylosis. The bones become 
solidly united together, leaving a permanently deformed and stiff neck. 
Diagnosis.-This disease in some of its features resembles cervical rheu- 
matism and syphilitic necrosis of the atlas. In cervical rheumatism, however, 
there is no pharyngeal swelling. Neither is there deformity, nor any pain 
on the application of pressure to the top of the head. 
In cases of syphilitic necrosis of the atlas, the bone disease is accompanied 
and often preceded by pharyngeal ulceration, and there is no prominence 
of the spinous process of the axis, even though a large part of the atlas may 
be discharged. 
Treatment.-Rest and immobility are of the first importance in the treat- 
ment of this disease. And these can be secured only while the patient is in 
the recumbent position. 
A piece of muslin must be cut so as to fit between the shoulders and to 
cover the back of the neck and the posterior part of the head. Over this 
two or three plaster rollers should be applied by recurrent turns, and the 
head and neck allowed to rest buried to some extent in a soft pillow. When 
the plaster becomes firmly set, the parts will have an equally distributed and 
safe support. 
The position in bed must be enforced for a long time, or until anchylosis 
has taken place. Even after the patient is able to assume the erect position 
the head will for some time demand an artificial support similar to that em- 
ployed in Pott's disease of the spine. 
The appropriate constitutional treatment will consist in exhibiting cod liver 
oil and iron, with a generous diet, and also opiates when necessary to relieve 
pain. 
Arthritis of the Sacro-Iliac Articulation. 
This is not a common affection. It is met with generally in young adults, 
rarely, if ever, in children. Though noticed by Boyer and Chelius, the 
best descriptions of this disease have been given by Hahn, Nelaton, and 
Erich sen. 
Causes.-The remote cause of this arthritis must be sought for in some 
specific constitutional predisposition, which, from exposure, exhaustion, or 
traumatic violence,-as when the pelvis has been subjected to severe com- 
pression, blows, or twists,-has been kindled into activity. 
Pathology.-The inflammation most probably begins in the synovial 
membrane, and extends to the cartilaginous components of the joint. There 
are not, however, wanting facts which seem to show that an osteitis of the 
ilium or of the sacrum may precede all articular change. 
As the disease progresses, the synovial membrane becomes thickened; ARTHRITIS OF THE SACRO-ILIAC ARTICULATION. 
197 
fungoid or pulpy granulations spring up in the joint; and these ultimately 
cause the utter disorganization of the articular cartilage, leaving the bones 
of the articulation uncovered, though without any marked tendency to either 
caries or necrosis. The ligaments also undergo a slow degeneration 
Symptoms.-The commencement of the disease is announced by a sense of 
pain, weakness, or weariness experienced between the hips, and aggravated 
by standing, walking, or even sitting. 
The pain is increased in coughing, sneezing, defecation, and urination, or 
in any straining efforts which call into play the muscles of the loins. It 
sometimes attains a great degree of severity, which will extort an outcry 
from the patient, particularly when the pelvis is twisted or when the ilium 
and the sacrum are pressed together. Walking gives rise to much uneasi- 
ness and to lameness, in which the body is advanced and the diseased limb 
favored as much as possible. 
In standing, the posture is peculiar: the body is inclined over to the sound 
side, so as to relieve the affected joint from all pressure and to secure some 
extension by the weight of the extremity. 
Swelling is an early symptom. It is at first seen in a line extending down 
from the posterior superior spinous process of the ilium, but not changing 
the form of the nates or the post-trochanteric depression. At a later period 
of the disease, however, and particularly when abscesses form, the swelling 
will extend to the buttock, materially altering its shape. 
The length of the limb is also increased,-a condition due to a downward 
rotation of the innominate bone of the affected side, and not to any actual 
elongation of the limb. This will be made apparent by comparing the an- 
terior superior spinous processes of the two innominata,-the one on the dis- 
eased side being on a lower plane than its fellow,-and also by measuring the 
distance between the same processes and the internal malleoli of the two 
ankles, which will be found to be the same in both extremities. 
When suppuration is established,-an event which occurs at an advanced 
stage of the disease,-the diagnosis can be certified by introducing a probe 
through the opening, provided the abscess discharges externally, when the 
probe may be carried down directly to the denuded bone. It is not always 
the case that the pus finds its way externally; it may enter the pelvis and 
be discharged into the rectum and be passed per anum; or it may find its 
way through the sacro-ischiatic foramen into the buttock; or, finally, it 
may descend between the obturator and the levator ani fasciae, reach the 
ischio-rectal fossa, and appear as a fluctuating swelling at the side of the 
anus. 
Diagnosis.-There are several affections with which sacro-iliac arthritis 
may be confounded. These are coxalgia, sciatica, and caries of the spine or 
bones of the pelvis. The disease may be thus distinguished from coxalgia: 
COXALGIA. 
A disease chiefly confined to children under 
twelve years. 
Pain generally at the knee or in the hip-joint. 
Limb everted and abducted at .first, and after- 
wards inverted and adducted. 
Early change in the form of the buttock, and 
loss of the gluteo-femoral crease. 
Movements of the limb restricted and painful, 
especially flexion and abduction. 
No pain when the patient is turned upon his 
breast and the sacrum and ilium are pressed firmly 
together. 
SACRO-ILIAC ARTHRITIS. 
Mostly occurring in young adults. 
Pain localized near the sacrum. 
Limb only elongated. 
No change in the form of the buttock, nor any 
obliteration of the gluteo-femoral crease, except 
in advanced stages of the disease. 
Movements neither painful nor restricted when 
made with the patient in the recumbent position 
and with the pelvis fixed. 
Pain severe under such treatment. 
From sciatica, sacro-iliac arthritis may be distinguished by the following 
peculiarities: 198 
DISEASES OF SPECIAL JOINTS. 
SCIATICA. 
Pain below the glutei muscles, and extending 
from the back of the thigh. 
Often followed by contraction of the hamstring 
muscles and slight flexion of the leg. 
No lengthening of the limb. 
No deformity of the pelvis. 
A disease generally of mature or advanced life. 
SACRO-ILIAC ARTHRITIS. 
Pain above and posterior to the glutei muscles, 
and does not extend down the limb. 
No flexion of the leg. 
Limb elongated. 
Deformity of the pelvis. 
A disease usually of young adults. 
In distinguishing sacro-iliac arthritis from disease of the spine, the follow- 
ing comparison of symptoms may be drawn : 
SPINE DISEASE. 
Prominence of certain vertebra, and antero- 
posterior curvature of some portion of the spine. 
No elongation of the limb. 
A disease generally of childhood. 
In some cases pressure over diseased vertebra 
causes pain. 
Patient walks with the spine rigidly fixed and 
straight, and without limping. 
In the event of an abscess forming and open- 
ing over or near the sacro-iliac synchondrosis, a 
flexible probe introduced into the opening will 
lead to the spine. 
SACRO-ILIAC ARTHRITIS. 
Neither. 
Elongation of the limb. 
Occurring generally in early manhood. 
Pain caused only by pressure over the sacro- 
iliac articulation. 
Patient bends forward in walking, and is lame. 
In abscess, the probe goes directly to the sacro- 
iliac joint. 
Caries and necrosis of the innominate bone give rise to symptoms resem- 
bling in some particulars those of sacro-iliac arthritis, particularly when the 
posterior part of the ilium is involved. But the diagnosis may be reached 
by remembering that in disease of the ilium the patient is able to stand and 
walk for a long time without any unusual suffering; there is no tilting of the 
pelvis, no elongation of the limb on the affected side; and, when abscesses 
form and open on the surface and an exploration is made with the probe, the 
necrosed portion of the bone will be found in a position different from that 
of the articulation between the sacrum and the ilium. 
Prognosis.-Disease of the sacro-iliac articulation is generally fatal, the 
patient being worn out by long-continued suppuration and hectic fever. The 
fatality may depend on the fact that the true nature of the affection is often 
not recognized until extensive disorganization of the joint has taken place. 
Treatment.-In order to relieve the affected wing of the pelvis from the 
evil effects of pressure and motion, the leg, the hip, and the pelvis should be 
encased in a plaster splint and the patient placed on crutches. At the same 
time he should wear a high-soled shoe on the foot of the sound limb, in order 
to prevent the weight of the body from resting at any time upon the dis- 
eased extremity. 
When the pain is severe, it will be better to confine the patient to the re- 
cumbent position, and to apply extension to the limb by means of a weight 
attached to the leg by adhesive plasters. 
When abscesses form, they must be opened freely, in order that the puru- 
lent accumulation may have a free escape; and when loose pieces of dead bone 
can be discovered, they should be promptly removed. 
During the long and exhausting period of suppuration, the system will 
require to be sustained by a nourishing diet, and by the use of tonics,-both 
the bitter and the ferruginous,-together with cod-liver oil and stimulants. 
Sterno-Clavicular and Acromio-Clavicular Arthritis. 
These are not uncommon affections. Of the sterno-clavicular arthritis I 
have witnessed several examples. The disease is generally met with in young 
subjects, and often gives rise to so little inconvenience for a long time that 
the function of the joint is but slightly interfered with. An army officer 
who occasionally consults me has been suffering with this disease in the ARTHRITIS IN JOINTS OF THE UPPER EXTREMITIES. 
199 
sterno-clavicular joint for over twenty years, and, although the articulation 
is open and suppuration going on, he persists in using the arm. 
Symptoms.-When either of these joints is attacked by inflammation, there 
is swelling, partly due to the synovitis and partly to inflammatory transuda- 
tion in the cellular tissue exterior to the articulation. Pain is felt on motion 
or on pressure. The end of the clavicle appears to be considerably enlarged, 
and is usually prominent. After a time suppuration occurs; and if the pus 
is not circumscribed by a w'all of lymph, it may, when the sterno-clavicular 
joint is the seat of the disease, find its way into the anterior mediastinum; 
or, if the acromial end of the clavicle be affected, the pus may find its way 
into the neck or into the supra-scapular region. 
In consequence of the magnitude of the interarticular cartilage and the 
size of the joint, the affection runs a very chronic course when seated at the 
sternal end of the clavicle. In time, however, if the inflammation be not 
controlled, the ends of the bone become carious, the ligaments soften and give 
way, and a spontaneous luxation follows. 
Treatment.-When the nature of the disease is detected early, a cure may 
be effected either by resolution or by anchylosis,-though rarely by the latter. 
The shoulder being movable, it is very difficult to secure perfect fixation. 
Yet this must be obtained to the fullest extent possible, by a roller applied as 
in the Velpeau dressing for fractured clavicle. This, as a matter of comfort, 
should be alternated with a sling of the forearm, the arm at the same time 
being secured to the body by a strip of muslin. 
Local applications do not seem to accomplish any very marked effects. 
Some benefit, I have thought, has followed the use of a plaster consisting of 
belladonna and iodoform and worn over the articulation. 
If the disease follows an acute course, the interarticular cartilage and the 
ligaments may be so rapidly destroyed as to allow the end of the bone to 
become luxated. Under such circumstances the clavicle must be reduced, 
and treated as in traumatic luxation. 
When necrosis supervenes and extends beyond the limits of the articular 
ends of the bone, at the same time exhibiting no tendency to separation, a 
resection of the diseased portion should be made. Between the opposing 
forces of the clavicular portion of the sterno-cleido-mastoid muscle above 
and the pectoralis major muscle below, and the restraint of the subclavius, 
the remaining part of the clavicle, when the arm is fixed, can be retained in 
a reasonably good position until it has contracted adhesions with the sur- 
rounding parts. 
When the osteitis lingers for a long time at the articular end of the clavicle, 
-which may be determined by the use of the probe,-the scraper or gouge 
may be used with advantage, exercising due care not to disturb the costo- 
clavicular or coraco-clavicular ligaments, according as the sternal or the acro- 
mial end of the bone is under treatment. The preservation of these ligaments 
serves to retain the clavicle in its place. 
Shoulder-Joint.-This articulation, though it resembles the hip-joint in its 
anatomical construction, is much less liable to disease of a strumous char- 
acter. Both children and adults are the subjects of tubercular inflammation 
in the shoulder-joint,-the latter more frequently than the former. Com- 
mencing as a synovitis, the morbid action, unless early checked, extends 
to the head of the humerus, and it may also involve the glenoid cavity of the 
scapula. Even the coracoid process of the latter is sometimes destroyed, as 
was the case in a very estimable judge in Philadelphia, who recently died 
from this affection. 
Symptoms.-The disease generally commences with some soreness and stiff- 
ness of the joint,-at first usually regarded as rheumatic. The shoulder 
becomes swollen; and severe pain is felt whenever the humerus is crowded 
Arthritis in Joints of the Upper Extremities. 200 
DISEASES OF SPECIAL JOINTS. 
against the scapula, sometimes extending down the arm in the course of the 
ulnar or musculo-spiral nerve, but oftener confined to the deltoid muscle. 
The muscles of the arm waste, and, unless the arthritis is soon arrested, sup- 
puration follows. This termination is announced by rigors, fever, and sweat- 
ing. Pus, once formed, after a time finds its way out of the joint, sometimes 
following the course of the long tendon of the biceps muscle and opening on 
the surface of the arm below the anterior fold of the axilla, or, forcing its 
way through the softened capsule of the joint, it may pass beneath the del- 
toid muscle and be discharged either through the fissure between this muscle 
and the pectoralis major in front or posteriorly between the scapula and the 
shoulder. 
Diagnosis.-The disease under consideration bears some resemblance to 
rheumatoid arthritis and bursitis. From the first it may be distinguished 
thus: 
STRUMOUS ARTHRITIS. 
A disease of children and of young adults. 
Head of the humerus remains unchanged in its 
position. 
No crepitus; or if crepitation, a moist one. 
Suppuration. 
Rigors, fever, and sweating. 
RHEUMATOID ARTHRITIS. 
A disease of mature and advanced life. 
Head of the humerus is raised and advanced 
forward; can be felt near the coracoid process. 
Crepitation rough. 
No suppuration. 
No rigors, fever, or sweating. 
The parts about the shoulder-joint which are prone to inflammation are 
the bursae lying under the deltoid, and the tendons of the subscapularis and 
infra-spinatus muscles. As the last two communicate with the articulation, 
they generally become involved in all cases of strumous disease of the scapulo- 
humeral joint, by extension of the inflammation from the synovial membrane 
outward. When the disease is primarily a bursitis of these sacs, it will be 
found that pain is developed when the arm is drawn away from the scapula 
and at the same time rotated either inward or outward. 
Forcing the articulating surfaces of the bones together, without rotation, 
does not cause pain in primary bursitis, but will do it in synovitis. 
When the bursa between the humerus and the deltoid is inflamed, all 
movements of the arm, when it is allowed to hang by the side, will cause suffer- 
ing. But when the limb is elevated, so as to relax the muscle, the humerus 
can be rotated or carried forward or backward without creating much un- 
easiness. Neither does forcing the head of the bone against the glenoid 
cavity of the scapula produce pain. These are tests that cannot be practiced 
in synovitis of the joint without causing complaint. 
Treatment.-The treatment consists in flexing the forearm across the 
chest and bringing the arm to the side, after which the Velpeau bandage can 
be applied in order to secure entire quiet for the shoulder. When this dress- 
ing becomes irksome, it may be changed for a sling to support the forearm, 
the arm being fastened to the side by a roller bandage. 
If, after the joint has been for some time in a state of repose, there is not 
a marked amelioration of the symptoms, a blister should be applied over the 
articulation. 
After vesication, the cuticle may be to some extent removed and the sur- 
face sprinkled with morphia. 
Should the disease run to suppuration, an early opening must be made and 
a free exit be provided for the pus, introducing, if necessary for this purpose, 
a drainage-tube. The patient, at this stage of the affection, will require a 
properly selected and nutritious diet, together with tonics,-as iodide of iron, 
tincture of sesquichloride of iron, quinine, and cod-liver oil, etc., with malt 
or alcoholic stimulants. 
When the case results in caries and necrosis of the bones, and the strength 
of the patient begins to fail, our only resort is excision. 
Elbow-Joint.-Strumous disease of the elbow-joint is, like that of the knee, 
protracted, and often very destructive to the components of the articulation. STRUMOUS DISEASE OF THE ELBOW-JOINT. 
201 
The disease may commence as a synovitis or as an osteitis. When the latter, 
the humerus is generally first involved; and here the caries may linger for a 
long time before extending to the bones of the forearm; when the latter 
event does occur, the ulna is usually implicated rather than the radius. 
Symptoms.-The phenomena attending the disease are pain, swelling, flex- 
ion, and rigidity of the articulation. The swelling, at first, is most marked 
on the posterior aspect of the joint,-that is, on each side of the olecranon 
process of the ulna, extending also some distance above the latter,-points 
where the least structural resistance is encountered. After some time, how- 
ever, all the bony prominences of the joint disappear, the swelling extending 
around the entire articulation, the skin at the same time becoming tense and 
shining. (Fig. 1070.) Both the arm and the forearm rapidly waste, and the 
least movement of the joint is attended with severe suffering. 
Fig. 1070. 
Strumous disease of the elbow-joint. 
When suppuration takes place, the pus travels in the direction of least op- 
position, up the back of the arm underneath the triceps, and the abscess dis- 
charges on one side or the other of that muscle. The dense character of the 
intermuscular fascia, and its connection or expansion above the inner condyle 
of the humerus, favor evacuation on the opposite or external side of the tri- 
ceps. Abscesses in front of the joint are not, as a rule, very common, and 
when they do occur it is in the more advanced stages of the disease, when 
they may find their way to the surface, generally on the outer side of the 
tendon of the biceps. This is due to the resistance of the bicipital aponeurosis 
on the inner side. 
Sinuses, nevertheless, may form at all points about the articulation, deter- 
mined very much by the inflammatory deposits in the extra-articular tissues. 
Sometimes they lead directly down to the diseased bone. At other times the 
passage may be a circuitous one. The humeral and olecranoid epiphyses 
may exfoliate in their entirety. It would seem that in cases of this kind 
the inflammatory attack has been primarily located in the cartilaginous 
structure uniting the diaphysis with the epiphysis; for the exfoliated piece 
often exhibits no evidence of having participated in the caries. 
Treatment.-Position and rest are the prime requisites in the treatment 
of strumous inflammation of the elbow-joint. The forearm should be flexed 
a little beyond a right angle with the arm, and placed midway between pro- 
nation and supination. The necessity for this latter position arises from the 
tendency of the radius to become displaced backward and upward,-an acci- 
dent w7hich would be favored by allowing the hand to fall, as it naturally 
does, into a state of pronation. 
In order to maintain permanently this position of the limb, a splint should 
be accurately moulded to the arm, extending from the axilla to the metacarpo- 
phalangeal articulations. In no way can this object be better attained than 
by covering in the extremity with a spiral reversed bandage and afterwards 
adding the plaster rollers. These must be applied from below upward by cir- 
cular turns, afterwards slitting up the dressing along the radial border of the 
forearm and the outer aspect of the arm; or the bandage may be applied, in 202 
DISEASES OF SPECIAL JOINTS. 
the same direction, in the form of recurrents, which will obviate the necessity 
of any subsequent cutting. As the articular swelling begins to diminish, it 
is important to follow it up by increased pressure. This may be done by 
dividing the roller next to the skin and overlapping and pinning together 
the strips; or the same end may be attained by placing around the joint, over 
the first roller, a piece of rubber cloth before applying the bandage; and this, 
by three or four tabs sewed on each side, can be tightened up as necessity 
arises. 
When the capsule of the joint is much distended with fluid, the use of the 
aspirator will be indicated. 
Among the local applications best adapted to moderate the articular in- 
flammation is the strong iodoform ointment, which should be applied daily 
over the surface of the swollen joint,-a trap being cut in the splint for the 
purpose. Blisters may be used for the same object. But I have never wit- 
nessed the striking results claimed by some writers to follow the use of vesi- 
cants ; and the same may be said of the actual cautery. 
The use, internally, of cod-liver oil and iodide of iron, together with a 
diet rich in the plastic materials of nutrition, is an essential element in the 
treatment. 
If management of the disease has been undertaken in its incipiency and 
faithfully carried out in all the specified details, it may undergo a favorable 
termination by resolution. And when, after from eight to twelve weeks, such 
a result appears to have been attained, the surgeon should very carefully 
and gently begin to make slight movements of the joint, with a view to 
restore its functions, cautiously increasing these manipulations, both as to 
time and extent, as the joint is found to tolerate them. 
When the disease terminates in suppuration, the pus should be first re- 
moved by aspiration, in hope that the articulation may yet be saved. If, how- 
ever, the pus again quickly accumulates and points on the surface, it will be 
better to lay the parts freely open and resort to the oakum or the rubber 
tube to establish a perfect drainage. Whenever the existence of carious or 
necrosed bone is made out, it should be removed. Occasionally it will be 
found that the disease is limited to a single bone or to one condyle; and 
when this is the case, the operation should be confined to the affected part. 
Oftener, however, the disorganization is much more extensive, and then the 
excision of the joint will be required. Should the bones, on examination, 
prove to be extensively diseased, that is, for some distance from their articular 
surfaces, and the health and strength of the patient be much deteriorated, 
amputation will offer a better chance of recovery. 
Wrist and. Carpal Joints.-Strumous inflammation of the wrist-joint ex- 
hibits a stronger tendency than does rheumatic disease to transcend the 
limits of the articulation and invade both the bones and joints of the carpus. 
The continuity of synovial tissue is particularly favorable for such a propa- 
gation of inflammatory disease. In addition to this, there is another peculi- 
arity of organization, which confers an unusual degree of interest on an ar- 
thritis of the radio-carpal joint,-namely, the numerous tendons which, with 
their serous coverings, pass to the hand over the anterior and posterior as- 
pects of the articulation. These sheaths or their lubricating membranes are 
liable to participate in the joint inflammation, increasing both the disability 
and the pain. 
Symptoms.-Arthritis of the radio-carpal joint presents very characteristic 
symptoms. The hand is slightly flexed, and there is a marked swelling on 
the back of the wrist, which eventually extends to the ends of the fingers, 
the latter becoming stiff, straight, and helpless. (Fig. 1071.) A little fullness 
may also be observed in front of the articulation, and the slightest motion of 
either the wrist or the fingers will be followed by severe paroxysms of pain. 
The swelling, at first soft,-consisting of increased synovial fluid,-may un- 
dergo one of two changes: it may either fluctuate upon pulsation, an evidence NERVOUS DISEASE OF JOINTS. 
203 
of suppuration, or present an elastic feel, occasioned, in most instances, by 
the formation of fungous granu- 
lations within the joint. 
When suppuration occurs, 
should the matter not find a 
ready outlet, a spontaneous luxa- 
tion backward-may follow. When 
the ligaments give way, the puru- 
lent matter is liable to travel up 
the arm, or downward into the 
hand, causing the most serious disorganization of the tissue. 
Treatment.-The forearm and hand must be placed at rest, in order to 
secure complete immobilization of the wrist-joint. The support usually em- 
ployed for this purpose, namely, a straight palmar splint, is not the best ar- 
rangement. It allows too much pronation of the hand, which increases the 
pressure of the carpal bones against the posterior radio-carpal ligaments. A 
better plan is to place the hand midway between pronation and supination, 
and, after applying a roller from the fingers to the elbow, to follow it with 
a plaster bandage, and afterwards to cut a trap over the back of the wrist, 
through which to inspect the joint or to make local applications. The forearm 
and hand, after being thus encased, should be placed across the chest and 
supported in a sling. As pressure is important, the same expedient may be 
resorted to as in arthritis of the elbow-joint, namely, the use of the rubber 
cloth placed between the splint and the first roller. 
When the swelling is soft and fluctuating, the fluid should be removed by 
the aspirator, and the iodoform ointment should be freely applied to the sur- 
face of the joint. The surgeon must be ever on the watch for the diffusion 
of matter amidst the muscles of the arm or in the direction of the hand ; and 
upon the earliest evidence of such an occurrence, he should open a way for 
its escape, afterwards keeping this way free by the use of drainage setons. 
When sinuses form about an articulation, a favorable opportunity is fur- 
nished for an exploration of the joint, which can be done by the use of the 
probe. 
Even though the articulating surfaces of the radius and ulna may be de- 
nuded, the condition is not incompatible with a cure by anchylosis. 
When the carpal bones become carious, little hope remains of saving the 
hand; and the only choice left to the surgeon is that between excision and 
amputation. 
Fig. 1071. 
Arthritis of the wrist. 
Nervous Disease of Joints. 
Pseudarthritis.-This affection, sometimes called " hysterical," and by Mr. 
Paget " nervous mimicry," consists in an unnatural exaggeration of some func- 
tional disturbance of an articulation. Females are, in most instances, the 
subjects of this variety of joint trouble, and those belonging, for the most 
part, to the higher classes of society,-a fact which was long since pointed 
out by Sir Benjamin Brodie. It may exist in persons who are not at all 
hysterical and who are by no means lacking in an energetic will, and in per- 
sons both under and over puberty, but rarely does it occur in those beyond 
mature life. 
The true character of this unreal disease is frequently not detected, and, 
to the discredit of the profession, the patient is often allowed to linger along 
for weary months, nursing her imaginary infirmity, and is sometimes sub- 
jected unnecessarily to leeching, blistering, and cauterization, and to an in- 
terminable succession of antispasmodics, until, perhaps, in a state of despera- 
tion, the medical attendant is displaced for some graceless charlatan, who 
dissolves the sham by the authoritative enforcement of a command. On the 
other hand, I have known the opposite error to be committed, and a patient 
seriously damaged by the use of violent measures to relieve a supposed func- 
tional condition of a joint, which in reality was an organic condition. 204 
DISEASES OF SPECIAL JOINTS. 
Symptoms.-A young woman, bred in luxury and indolence, and whose 
mind has been systematically occupied with subjects which appeal largely 
to the imagination, suddenly complains of pain in the knee or the hip. The 
articulation is rigidly fixed, and generally in the extended position. The 
joint becomes excessively sensitive, perhaps slightly swollen. The most 
delicate touch of a finger over the surface causes intense pain, and the slightest 
movement of the limb is followed by agonizing suffering. After some time, 
and in consequence of disuse, the circulation becomes sluggish, the ex- 
tremity presents a bluish or mottled appearance, and the surface tempera- 
ture falls below the normal standard, especially during the early part of the 
day. Towards evening the heat of the limb may be much increased. Ex- 
cept in very protracted cases there is little muscular or fatty atrophy of the 
part. 
In some instances the symptoms exhibit a marked tendency to periodicity, 
-the pain coming on only at a particular part of the day, when it may con- 
tinue for several hours, and then gradually subside. Notwithstanding the 
acute local suffering, there is an entire absence of fever. The appetite and 
general health are very little impaired. 
In other cases we find this nervous condition in persons who neither by 
education nor by the exactions of social life have been rendered morbidly 
sensitive, but who, on the contrary, possess a more than ordinarily vigor- 
ous intellect and a marked independence of character. Such individuals 
are often endowed with a highly sympathetic nature, and will frequently 
compassionate the sufferings of others to a degree which makes them in a 
measure their own. I have seen a number of instances in which persons, 
both male and female, believed they had become the subjects of the diseases 
from which friends had died; describing all the symptoms which they expe- 
rienced with a vividness which at once aroused a suspicion of their unreal 
character. Females, in great dread of cancer, have consulted me, complain- 
ing of intense pains shooting through the mammary gland, all of which dis- 
appeared on their being assured that there was not a trace of disease present. 
Causes.-An attack of this form of joint disease can often be traced either 
to uterine displacements or to some derangement of the menstrual function. 
In three instances I have seen it occur in the hip from intra-pelvic cancer 
causing pressure upon the obturator nerve. Mr. Erichsen mentions a case of 
the disease arising from this cause. Often the cause appears to be purely 
psychological. It has occurred to me to meet with pseudarthritis oftenest 
in females with black hair and dark complexion, and in whom the capillary 
circulation was sluggish. 
Diagnosis.-The diseases with which pseudarthritis, or "hysterical" joint- 
disease, is liable to be confounded are arthritis, coxalgia, white swelling, and 
feigned articular disease. 
Pseudarthritis may be distinguished from arthritis by attending to the 
following considerations: 
PSEUD ARTHRITIS. 
Generally seen in females. 
Joint slightly or not at all swollen. 
Without redness. 
Greater tenderness complained of from a slight 
touch than when the part is firmly pressed upon. 
Pain superficial. 
Manifestations of pain overstated. 
Limb remains unchanged. 
Temperature under rather than over the natural 
degree. 
Attack sudden. 
Flexion of the limb occasionally present. 
Twitchings of the muscles sometimes present, 
though not attended by any increase of pain; and 
always ceasing as the patient falls asleep. 
No constitutional disturbance. 
ARTHRITIS. 
Seen in males and females with nearly equal 
frequency. 
Marked swelling of the joint. 
Often with redness. 
Pressure painful only when firm. 
Pain deep-seated. 
Not exaggerated. 
Limb wastes. 
Temperature over the normal standard. 
Attack usually gradual. 
Flexion always present. 
Spasms or starts of the muscles of the limb en- 
tailing acute pain at the time, and often occurring 
as the patient falls into sleep. 
Constitutional disturbance generally present. NERVOUS DISEASE OF JOINTS. 
205 
From coxalgia and white swelling pseudarthritis may be distinguished 
without difficulty. 
PSEUDARTHRITIS. 
Sudden in its attacks. 
Pain diffused. 
Nutrition of the limb but little, if at all, im- 
paired; the surface never shining and polished. 
External features of the joint unchanged. 
Crowding together the joint surfaces causes no 
pain. 
Direction or attitude of the limb but little, if 
at all, changed. 
No tendency to suppuration. 
HIP AND KNEE-JOINT DISEASE. 
Gradual in development. 
Pain localized, and generally at the inner side 
of the knee, in both hip and knee-joint disease. 
Limb wasted. 
Flattening of the buttocks, and obliteration of 
the gluteo-femoral crease, in hip disease; disap- 
pearance of the depression on each side of the 
patella, in knee-joint disease. 
Causes pain. 
Limb flexed, abducted, and rotated outward 
in the first stage of coxalgia; and the knee flexed 
in white swelling. 
Frequently abscesses, both external and inter- 
nal to the joint. 
Ancesthetics may be used with great advantage in clearing up obscure cases 
of joint affections. When the will is rendered incapable of influencing the 
muscles, the movements of the articulation, in the absence of disease, will 
be free and unrestrained. 
The hot iron brought in close contact with the affected limb will often 
reveal the true nature of the case, when the disease is unreal, by the quick- 
ness with which the part is withdrawn and moved about, without any cry 
or scream referable to pain. 
Treatment.- A careful examination should be instituted in all cases of 
pseudarthritis, with a view to ascertain if there is any material explanation 
for the condition. If there is leucorrhoea, dysmenorrhcea, or endometritis, 
it should be corrected by proper remedies. In the event of uterine displace- 
ment, the malposition must be rectified. 
If the patient is ansemic and the general health is deteriorated, iron con- 
joined with antispasmodics should be given. The best combination, accord- 
ing to my experience, is valerianate of iron with assafoetida, and bromide of 
camphor. The shower-bath, or sea-bathing, will often be found a valuable 
adjuvant to the treatment. 
The propel' local remedies are massage, manipulation, and electro-galvanism. 
The patient must be encouraged to use the limb systematically, say two 
or three times each day, at a given hour, and every day to increase the ex- 
ercise, receiving some encouraging words for every voluntary effort put 
forth, until, by degrees, the usual functions of the limb are restored. 
It will not do to let the patient understand that the malady is deemed an 
unreal one. Such a course will fail to secure that confidence which so largely 
contributes to the success of the treatment. The effect of proper mental im- 
pressions cannot be over-estimated in the management of this singular form 
of joint disturbance. And on this account it may be necessary to remove 
the patient from her friends, in order that an entirely new direction may be 
given to the thoughts, and that the demoralizing influence of unwise sympathy 
may be avoided. CHAPTER XIII. 
EXCISION OF JOINTS AND BONES. 
Excision, sometimes designated resection, may be executed in the continuity 
or in the contiguity of bones,-that is, at any point respectively between or 
through their articulating extremities. 
Excision in continuity is a very ancient operation. References are made 
by ancient writers to this mode of dealing with caries, as also with diseased 
joints, and with the broken ends of bones in compound fractures, when pro- 
truding through the external wound. In the last-named cases, Hippocrates 
advised that the protruding ends, when not reducible, should be cut off. 
The instructions of Celsus and Albucasis are to the same effect. Paulus 
JEgineta recommended the removal of entire bones, like the radius and the 
ulna, when diseased, and speaks of the propriety of cutting away portions of 
osseous tissue near to an articulation. Fabricius Hildanus, in 1670, removed 
the astragalus for a compound luxation of that bone. 
The first resection appears to have been performed by Cooper, of Bungay, 
England, in 1750. The lower articular extremities of the radius and the 
ulna were removed by this surgeon. About the same time, Dr. Schlichting 
reported the removal of the head of the femur from a patient suffering 
from hip disease. In 1758, Wainman, of Sbripton-in-Craven, in a case of 
compound luxation of the elbow-joint, excised the condyles of the humerus 
with a successful result. In this case the patient owed the preservation of 
his arm to the unwillingness of the family to have it amputated. Four 
years later (1762), Mr. Filkin, of Northwich, unable to secure the consent of 
the patient's friends to an amputation, removed the articulating ends of the 
femur and the tibia, together with the patella, for disease of the knee-joint. 
Mr. Filkin had evidently been contemplating the excision of diseased joints, 
as he had previously performed the operation on the dead body. In the 
same year, Bagieu, of France, executed a partial excision of the wrist. In 
1767, Vigaroux, of Montpellier, excised the head of the humerus, and about 
the same time a similar operation was executed by David. 
During the succeeding ten years excisions of the upper extremity of the 
humerus and of the elbow were performed for caries,-one in 1768, by 
White, of Manchester; one in 1771, by Mr. Bent, of Newcastle; one in 
1778, by Mr. Ored, of Chester; and one in 1775, of the elbow, by Justamond. 
The success attending these operations had no small influence in extending 
the practice of excision to other articulations. 
In 1781, Mr. Park, of Liverpool, successfully excised the knee-joint of a 
Scotch sailor, thirty-three years of age, who had been suffering for ten years. 
On June 20, 1782, the same surgeon repeated this operation on a man thirty 
years old, but with an unfavorable result, the patient dying on the 13th of 
the ensuing October. The subject of treating joint disease by a more con- 
servative plan than that by amputation had been with Mr. Park (as his 
letter to Percival Pott clearly shows) a matter of serious consideration long 
before he executed this operation. He had demonstrated upon the cadaver 
the feasibility of excising both the knee and the elbow articulation, and 
had fully weighed all the difficulties attending the operation, and also the 
probable utility of the limb, if successful. The views of Mr. Park as to ex- 
cision, and the results of his two published cases, appear to have attracted 
very little attention from the British profession, as we learn that during the 
206 EXCISIONS. 
207 
long and bloody war which succeeded their publication not a single excision 
was performed by either the naval or the military surgeons of the realm. 
In 1784 Mr. Park's observations were translated into French by Professor 
Lassus, and it is thought that to this circumstance may be attributed the in- 
terest taken in the subject by the Moreaus. This, however, is very improb- 
able, as the elder Moreau had in 1782, two years previous to the publication 
of Park's paper in France, successfully removed the lower extremities of the 
tibia and fibula on account of caries, in a case the history of which bad been 
communicated to the Academy of Surgery in Paris. 
In 1786 the elder Moreau removed the shoulder-joint, and in 1792 the 
elbow-joint. Subsequently, he and his son at different times excised the 
shoulder-, the knee-, the ankle-, and the wrist-joint. Between this time and 
1794 followed the operations of Sommeillier, Larrey, Percy, and Willaume, 
on the shoulder. Mulder, of Groningen, who, after White, had advocated the 
applicability of the operation to the head of the femur, in 1809 excised the 
knee. The operations of Poux in 1819, and of Sir Philip Crampton in 1823, 
on the elbow-joint, were in 1825 succeeded by those of Syme, of Edinburgh, 
Bilguer, of Germany, and Hey, of Leeds. 
The publication of Mr. Syme's fourteen cases of excision of the elbow-joint 
exerted no small influence in awakening a new interest in this subject,-an 
interest which was increased by the operations of Textor, Heyfelder, Liston, 
and Fergusson, especially the latter. 
Conditions requiring Excisions in the Continuity of Bones.-1. In 
compound fractures where the ends of the fragments project through the 
external wound and cannot be replaced by the usual methods employed for 
reduction. 
2. In ununited fractures, after other and safer means have failed to secure 
consolidation. 
3. In cases of vicious union after fracture it may be necessary to remove 
a portion of the bone in order to correct deformity. 
4. A bone may be comminuted by shot or other violence and require 
partial excision. 
5. In caries and necrosis it is frequently necessary to excise the diseased 
bone. 
6. In cases of extreme bending of bones following rickets a partial excision 
may be demanded. 
Conditions requiring Excisions in Contiguity.-1. In many cases of 
compound luxations before reducing the articulating ends of the bones. 
2. In caries of joints without any tendency to anchylosis, and in which the 
suppuration and the resulting constitutional irritation are making serious 
inroads on the general health of the patient. 
3. In badly-comminuted fractures, involving the articulating extremities 
of the bones, without lesion of the principal blood-vessels or too extensive 
destruction of the surrounding soft parts. 
4. Occasionally in anchylosis, with great deformity of the limb. 
5. In old unreduced luxations, in which the head of the bone, by pressure 
on important nerves, occasions much pain and disability. 
6. In cases of varus or valgus in the adult, not correctible by ordinary 
measures, portions of the tarsus may be excised. 
7. Occasionally in genu valgum. 
Conditions contra-indicating Excisions.-1. When so much of a bone is 
diseased that its removal would render the limb useless for support or pre- 
hension, it will be better to amputate. In the upper extremity a much larger 
amount of bone can be excised without impairing the use of the limb than in 
the lower. 
2. When the joint surfaces are involved in malignant disease, it is better to 
amputate. 
3. When the health of the patient is greatly impaired by previous disease, 
and consequently the body rendered incapable of resisting the exhaustion 208 
EXCISION OF JOINTS AND BONES. 
attending a protracted suppuration. Especially is excision contra-indicated 
if there are present the physical evidences of tubercular disease of the lungs 
or disease of the kidneys. If, however, the general health appears to be 
slowly yielding to the local irritation, pain, and suppuration which are in- 
cident to the disease, the operation will not be contra-indicated. 
4. In patients very young, or in those past mature life, and if also the ar- 
ticulation belongs to the lower extremity. The reparative resources of early 
childhood are very great and very active, and it is difficult to fix limits to 
the possibilities of spontaneous cure in this class by anchylosis, exfoliation, 
or resolution. There is another condition which makes it undesirable to cut 
away the epiphyses of young bones: the operation puts an end to the growth 
of the limb in length. 
5. During the presence of acute inflammation or abscess in a joint, or when 
the system is perturbed by traumatic fever, the prospects of success being 
greatly enhanced by allowing the disease to become chronic before any oper- 
ative interference is attempted. The plastic infiltration, which extends into 
the tissues some distance beyond the seat of the disease, presents a barrier 
against the formation of diffuse abscesses and the intrusion of the products 
of tissue-change into the system. Patients who have been the subjects of 
chronic joint or bone disease for a considerable length of time acquire a 
■wonderful tolerance of cutting operations. 
6. When there is a tendency to anchylosis the knife must be withheld. 
7. When, in addition to articular disease, there are present symptoms of 
osteo-myelitis, which, of course, would make the excision valueless, amputa- 
tion should be substituted. 
8. When the inflammatory action, or caries in the joint surfaces of the 
bones, is rapidly extending,-a state of things usually associated with a 
deeply-implanted strumous vice of the system, unfavorable to the operation. 
Reparation following Excision.-When a portion of bone is excised, or 
when a joint is resected, their opposite extremities may come together and 
unite by the interposition of callus. When the interspace resulting from 
the excision is great, or when the ends of the bone or bones are kept some 
distance asunder, the gap is not bridged over by new bone, but is occu- 
pied by fibrous tissue, which, from the mobility of the parts, in time acquires 
great thickness, density, and strength. 
If, however, in excising bones, in either their continuity or their contiguity, 
the periosteum is preserved, a certain amount of new bone may be obtained to 
take the place of the portion removed. The experiments of Troja and Syme, 
and, more recently, those of Ollier, and my own,* establish beyond all 
controversy the osteogenetic properties of the periosteum. The extent to 
which this membrane is capable of effecting repair will depend on its density 
and form. If, previous to an operation on a diseased bone, the periosteum 
is found thickened and readily separated in its entirety, possessing at the 
same time sufficient resistance to maintain its form, it will with great cer- 
tainty supply a new bone. In a case of phosphorous necrosis of the inferior 
maxillary, in which the entire bone was shelled out by Dr. William Hunt, 
the jaw was restored almost to its primal perfection. Other examples of a 
similar kind have been furnished by writers. I have seen the entire clavicle 
reproduced. 
When, however, the periosteum is thin, and, after detachment, its surfaces 
are allowed to fall together, no orderly reproduction of osseous matter, so 
far as my observation extends, may be looked for. Any new bone which 
in such a case does appear is deposited in little, disconnected masses, rather 
than in a continuous and firmly-constructed piece. 
It is chiefly in the long bones that we may expect to find this reparative 
work of the periosteum, though it is occasionally witnessed after subperios- 
teal excision of the short or irregular bones. To secure the full bone-pro- 
ducing operation of the periosteum, Sedillot advocates an operation which 
* Address on Repair of Bone, delivered before the Philadelphia County Medical Society. EXCISIONS. 
209 
he styles " 1'evidement des os," which consists in gouging out the osseous 
tissue, leaving only a thin shell covered with its investing membrane. 
Another matter of paramount importance in an excisional operation is its 
influence on the subsequent development or growth of the bone. Bones grow 
in length through the agency of a plate of cartilage interposed between the 
diaphysis and the epiphysis. Should the whole of the epiphysis be removed, 
there is an end to the further longitudinal growth of the bone so far as the 
excised extremity «is concerned. Consequently, the diseased limb cannot 
keep pace with the development of the other. It might be supposed that, 
when an operation of this nature becomes necessary, the epiphysis at the 
other extremity of the bone would, under the law of necessity, be stimulated 
to increased activity and thereby compensate for the loss of its fellow. But 
it must not be forgotten that the upper and lower epiphyses of the long bones 
are not equally concerned in the work of development. In the femur and 
in the radius, for example, the longitudinal growth is principally effected 
by the loioer epiphysis; while in the leg and the arm it is chiefly accomplished 
at the upper epiphysis of the tibia and the humerus. 
When the skeleton has attained its full growth, and the diaphysis and 
epiphysis become blended into a single piece, as is usually the case after the 
twentieth year of age, any excision performed can shorten the limb only in 
proportion to the thickness of the piece removed. 
Instruments required for Excision.-The instruments necessary for re- 
secting bones are the following: an ordinary scalpel, with which to make the 
Fig. 1072. 
Periosteal elevator. 
preliminary incisions for the exposure of the bone or the joint; a pair of 
forceps, to aid in the dissection of flaps; a tourniquet, to control hemorrhage; 
two strong bistouries, with short blades, one sharp and the other probe-pointed, 
Fig. 1073. 
Retractors. 
to be used, respectively, in dividing ligaments and in shaving the muscles 
away from the bone; a narrow periosteal elevator (Figs. 1072, 1075); retrac- 
tors, to hold the sides of the wounds apart (Fig. 1073); a shield, consisting 
Fig. 1074. 
Bone director. 
of a piece of soft wood or a strip of hammered sole leather, designed to be 
passed between the bones and the soft parts, in order to protect the latter 
from injury during the use of the saw; and a bone director (Fig. 1074). 
VOL. II.-14 210 
EXCISION OF JOINTS AND BONES. 
To divide the bone a number of saws should be at hand. Mr. Butcher has 
constructed one which bears his name (Fig. 1076), and which is admirably 
Fig. 1075. 
Narrow periosteal elevator. 
adapted for this purpose by its narrow blade, which can be made to cut 
in any direction, and enables the operator to make the section at any degree 
Fig. 1076. 
Butcher's saw. 
of obliquity. It will be desirable also to have a chain-saw (Fig. 1077), a 
metacarpal saw (Fig. 1078), and a semicircular saw (Fig. 1079). 
Fig. 1077. 
Fig. 1079. 
Chain-saw. 
Fig. 1078. 
Metacarpal saw. 
Semicircular saw. 
In addition to these instruments, there will be required a pair of strong lion 
forceps (Fig. 1080); straight and curved forceps (Fig. 1081), which can be 
used to steady the bone during its division; cutting pliers, straight and curved 
(Figs. 1082, 1083), and a gouge (Fig. 1084),-the former for cutting away EXCISIONS. 
211 
either the articular ends of bones or projecting spiculse, and the latter for 
gouging out any portions of osseous tissue which may not be altogether 
sound. 
Fig. 1080. 
Fig. 1081. 
Fig. 1082. Fig. 1083. Fig. 1084. 
Lion orceps. 
Curved pliers. 
Straight and curved cutting pliers. 
Rules to be observed in Excisions.-It is impossible, of course, to in- 
clude in these rules every detail attending an excision. But general direc- 
tions can be given which will serve to govern these operations. 
1. The patient, with few exceptions, should be placed in the recumbent 
position and be put under an anaesthetic. 
2. When a major joint is to be excised, there should be at least four assist- 
ants present,-one to administer the anaesthetic, two to support the limb, and 
the fourth to sponge the wound, hand instruments, and aid in the ligature 
of vessels. 
3. A tourniquet must be placed loosely about the limb when it is feasible, 
and tightened in the event of the bleeding becoming profuse. 
The Esmarch elastic bandage, though it renders the operation bloodless, 
is always followed by so much bleeding after its removal that I am not 
partial to its use. 
4. The incision should be planned so as to give the fullest exposure of the 
articulation, at the same time disturbing as little as possible the tendinous 
attachment of muscles, and avoiding important blood-vessels and nerves in 
the vicinity of the joint. 
5. The bones should be thoroughly isolated from all their surrounding con- 
nections, and should be generally pushed through the external wound before 
being cut off by the saw, the deep parts being protected by the interposition 
of the leather or wooden shield. 
When the chain-saw is employed, it may not be necessary to bring the 
bones out before their division. 
6. No more bone should be removed than is necessary to include the dis- 
ease; and in children the section should not include the whole of the epiphysis, 
otherwise the longitudinal growth of the limb will be arrested. In cases of 
Gouge. 212 
EXCISION OF SPECIAL JOINTS AND BONES. 
adults, where such a precaution is not necessary, it is, nevertheless, desirable 
not to trench upon the medullary canal, as the risk both of caries and of 
constitutional infection is thereby increased. 
7. When two bones parallel with each other are to be removed, they should 
be divided on the same level. 
8. The excision of the articulating extremities should always be made 
beyond the attachment of the capsular ligaments, as the danger of inflamma- 
tion is thereby lessened. 
9. It is not necessary to remove portions of bone which are studded with 
rough and irregular osteophytes, or which are somewhat rarefied and softened 
by their proximity to the diseased part. Such portions, when no longer in 
contact with the disorganized articular ends, generally return to a healthy 
condition. 
10. After the arrest of hemorrhage, the wound must be freed from blood- 
clots and foreign material by being thoroughly washed out, either by a shower 
of tepid water from a sponge or by the use of a syringe. Its edges are next 
to be brought together by the interrupted suture, a drainage-tube or a twist 
of oakum having been previously introduced, so as to secure at the most 
dependent part a free escape of all inflammatory products. 
11. If the operation has been done antiseptically, the antiseptic dressing 
in all its details will be necessary; if not, the part may be enveloped in a 
laudanum-and-water dressing and covered in loosely by the turns of a roller. 
The limb must next be placed in a splint which will secure the utmost quiet; 
nothing answers so well for this purpose as plaster. 
12. The position must be that which it is desirable to maintain throughout 
the subsequent treatment. As it is important, in exsections of the joints of 
the upper extremity, to preserve motion at the seat of the operation, after 
the inflammatory stage is passed, passive movements will be required. At 
the knee and the ankle, however, the limb will be most useful when the excised 
surfaces of the bones are solidly united together by new bone; and hence it 
would be improper to disturb them. 
13. The constitutional treatment necessary after excision consists in re- 
lieving pain and controlling muscular spasms by opiates, given either by the 
mouth or hypodermically. Synovial fever will be best relieved by the em- 
ployment of the neutral mixture; and, when suppuration sets in, the system 
must be supported by a good diet, tonics, and, perhaps, stimulants. 
14. When the wound refuses to heal, there will be ground for concluding 
either that all the diseased bone was not removed, or that the disease has 
commenced anew. Should abscesses form, followed by sinuses which refuse 
to close, the probabilities of a renewal of the caries will be increased. 
Under these circumstances a second excision is allowable, in case it does 
not necessitate too great a loss of bone, in which event amputation may be 
preferable. 
EXCISION OF SPECIAL JOINTS AND BONES. 
Excision of the Shoulder-Joint.-Excision of the shoulder-joint may become 
necessary in consequence of gunshot injuries or of caries of the head of the 
humerus; from fractures attended with comminution; and in cases of old 
luxations, in -which the bone presses injuriously upon the axillary nerves. It 
may also be required after an intracapsular fracture, in which the head of 
the bone, lying loose in the joint, gives rise to abscesses. In 1869, Professor 
Warren, of Baltimore, performed successfully an operation of this nature. 
In a large majority of cases wherein excision has been performed at this 
articulation for disease, only the head of the humerus has been removed, 
the glenoid cavity not participating in the caries or necrosis. The same is 
true when the operation has been done for shot injury. Extirpation of the 
shoulder-joint has been practiced for malignant disease, and for bony tumors 
involving the upper extremity of the humerus. Excision for carcinoma is EXCISION OF THE SHOULDER-JOINT. 
213 
not proper. When an operation for a disease of this nature is demanded, 
it should be amputation. 
Operation.-The operation may be divided into three stages: first, the 
exposure of the head of the humerus; second, the separation of its attach- 
ments; and, third, its removal. 
Exposure.-The patient having been etherized, and the affected shoulder 
brought over the edge of the table, a straight incision, five inches in length, 
should be made, commencing at the acromion process of the scapula, and 
carried vertically down the arm, extending through the integument and the 
belly of the deltoid muscle directly down to the capsular ligament and the 
bone. By this method the fewest fasciculi of the muscle are severed,-a 
matter of much importance. 
Any vessels which spring must now be secured. Generally two or three 
branches of the circumflex artery will require a thread. 
Drawing the sides of the wound well asunder, the muscle should be next 
separated, by a few touches of the knife, from its cellular connections with 
the capsular ligament of the joint. This will give a better exposure of the 
parts. The arm is now to be carried close to the side, and pushed upward, 
in order to stretch the capsular ligament over the head of the bone. The 
bone must now be divided. If the operation is to be performed for chronic 
disease of the joint, the ligaments may be found completely disorganized. 
The second stage consists in liberating the head and neck of the humerus 
and enabling the operator to thrust the bone through the external wound. 
This can be done in two ways,-either by direct division or by the subperiosteal 
method of Ollier. 
In the first plan the tendons of the scapular muscles are cut through at 
their attachments to the greater and lesser tuberosities of the humerus. This 
is readily accomplished by placing these structures on the stretch, by first 
rotating the arm strongly inward (which will facilitate the division of the 
tendons of the supra-spinatus, infra-spinatus, and teres minor muscles), and 
afterwards rotating it outward (which brings into view the attachment of 
the subscapularis muscle), after which the head of the humerus can be forced 
through the external opening in the soft parts. The tendon of the biceps 
muscle must be preserved entire, by being dissected out of its sheath and 
held out of the way. 
The other method requires for its execution, after opening the capsule, an 
elevator, by which the ligaments with the periosteum and the tendinous in- 
sertions of the muscles can be separated from the bone to the extent of the 
disease. This last plan, though not so quickly accomplished as the first, has 
the advantage, when successfully executed, of restoring to some extent the 
removed bone and its muscular connections, and consequently, when the 
patient recovers, there are less shortening and a better command of the 
arm. 
The third stage of the operation consists in removing the head of the bone. 
In doing this the arm should be carried either backward or forward, in 
order to direct the head and neck of the bone externally. The sides of the 
wound must be held apart by the retractors; and to protect the deep-seated 
parts from damage the wooden or leather shield must be interposed between 
the latter and the bone while the diseased portion is divided by the saw. 
(Fig. 1085.) 
Should the glenoid cavity be found to participate in the disease, it must be 
treated either by gouging or by excision. The curved cutting pliers can be 
used with advantage for this latter purpose. 
After the diseased bone has been removed and all vessels requiring ligature 
have been secured, the wound must be thoroughly cleansed, and its sides 
brought together by the interrupted suture, a rubber tube or an oakum seton 
having been previously introduced and brought out at the lower extremity 
of the wound, so as to secure free drainage. 
The shoulder is now covered with a pledget of lint wet with water; or, 214 
EXCISION OF SPECIAL JOINTS AND BONES. 
if the operation is done antiseptically, with the carbolated gauze and the 
Mackintosh cloth, over which is to be applied loosely a spica roller. 
Finally, the arm is 
brought to the side, 
with the forearm flexed 
across the chest, and 
supported in a sling, a 
wedge-shaped pad hav- 
ing been previously 
placed in the axilla, to 
keep the humerus out 
from the body. This 
sling should not only 
support the arm, but 
raise it up towards the 
scapula, so as to favor 
the shortening of the 
muscles, and, conse- 
quently, to bring the 
humerus nearer to the 
glenoid cavity,-a posi- 
tion favorable to the 
future power and use- 
fulness of the limb. 
Usefulness of the Arm.-After recovery, in successful cases, the arm can 
be moved forward, backward, and to the side with great ease and with con- 
siderable power, and is capable of carrying heavy weights, even where as 
much as five inches of the bone have been removed. Except in the flattening 
of the deltoid, the shoulder is very little changed in appearance. Flexion, 
extension, and rotation of the forearm are but little impaired, while all the 
functions of the hand can be executed with a completeness little inferior to 
that of its fellow. 
The movement most defective is that of abduction. The arm can rarely 
be elevated beyond a right angle with the body. This is due to the dis- 
advantage at which the deltoid acts. But in one instance, narrated in the 
" Surgery of the War,"-that of a private in a New York cavalry regiment, 
wounded by a shell, in rhe shoulder, at Culpeper,-the head and five inches 
of the humerus were excised, and yet after the recovery of the patient he 
was able to place the hand of the injured arm on the top of his head, and 
carry weight amounting to two hundred pounds. 
Even in cases where, on account of the amount of bone removed, the arm 
hangs limp and weak by the side, the fact that the forearm and the hand 
remain capable of executing multiform prehensile acts is a compensation 
which no human mechanism can approach. Nine times during the War of 
the Rebellion as much as 7 or 8 inches of the humerus were excised ; twenty- 
three times, 4 inches; eleven times, 4? inches; and seven times, 5 inches, 
without seriously impairing the functions of the arm. 
Shape of incisions.-There are quite a number of different-shaped incisions 
practiced by different surgeons for exposing the joint. White, Bellamy, 
MacCormac, Larrey, Gross, Bryant, and Langenbeck adopt the longitudinal, 
-the one which I have found to answer the purpose, and which inflicts the 
least injury on the deltoid. Pancoast advises an S-shaped incision. Moreau 
made two longitudinal incisions,-one in front of and one behind the deltoid 
muscle,-uniting these by a transverse cut made below the acromion process. 
This operation not only endangers the cephalic vein in front, but necessarily 
cripples the deltoid by its extensive division. Sabatier, Wattman, and Ham- 
ilton prefer a V-shaped incision. Morel, Fergusson, Bell, and Stromeyer 
adopted the semilunar flaps, with the convexity downward; and Erichsen 
and Gant make their incisions U-shaped. Others, like Syme, preferred an 
Fig. 1085. 
Excision of the shoulder-joint. EXCISION OF THE SHOULDER-JOINT. 
215 
L-shaped cut; or, with Bouzaires, a Y-shaped; and others again, a T-shaped, 
as practiced by Bent. 
History of Excision of the Shoulder-Joint.-Excisions of the scapulo- 
humeral joint, more or less complete, on account of disease, were very early 
performed. The earliest of which we have any record was done in 1740, 
by Thomas, of Pezenas, in Languedoc, for necrosis of the head and upper 
part of the shaft of the humerus; and in 1767 operations somewhat similar 
were done by the French surgeons Vigaroux, of Montpellier, and David, of 
Rouen. 
The first excision of the scapulo-humeral joint for shot injuries appears 
to have been done by a French surgeon named Grosbois, in 1796, on the 
person of a corporal wounded at Roveredo; and the second instance of a 
similar operation is attributed to M. Poret, in 1809. Operations for com- 
minuted gunshot fractures of the upper end of the humerus were executed 
by Boucher in 1745, by Larrcy, during Napoleon's wars, as early as 1793, 
and by Guthrie in 1812. In many of these cases of disease and shot injury 
the excision consisted in enlarging existing sinuses or wounds and extracting 
the exfoliated or broken pieces of bone. The first deliberately-planned ex- 
cision of the shoulder-joint was done by White, of Manchester, in 1768, for 
necrosis. The operation was limited to the upper extremity of the humerus. 
Moreau the elder made the first complete excision, having cut away the head 
of the humerus, the glenoid cavity, and a part of the acromion process of 
the scapula. In the interval between White's and Moreau's operations a 
number of partial excisions for disease were performed,-one, in 1770, by 
Ridewald, for rheumatoid arthritis, and in the following year one by Bent 
and one by Lenton, both for necrosis. The last was particularly worthy of 
note, as the entire humerus was removed, except about two inches of its 
lower extremity. Baron Percy, as early as 1794, is said to have exhibited, 
in Paris, nine cases of excision of the head of the humerus. And there can 
be no doubt that Larrey, in a number of instances of shot fractures detach- 
ing the shaft from the head, extracted the latter by an incision through the 
deltoid. 
In this country, the first excision of the scapulo-humeral joint for gunshot 
injury was performed by William Ingalls, of Boston, Massachusetts, in 1813. 
Succeeding this were the operations of Brown, Walker, Mann, Hunt, and 
McCook, in 1814. In 1826 the last-named surgeon did the same operation 
for disease of the bone. 
Hennen, as late as 1820, in speaking on this subject, used the following 
language: "I am disposed to think that the excision of the head of the 
humerus will be found to be more imposing in the closet than generally ap- 
plicable in the field." The experience, however, of English, Continental, 
and American military surgeons has established the operation on a solid 
foundation of facts, which renders its propriety under certain circumstances 
unassailable. 
Dr. Hodges has tabulated 475 cases of excision at the shoulder-joint for 
shot wounds, 252 being primary and 223 secondary operations. The mor- 
tality of the first was 23 per cent., and that of the second 38 per cent. The 
same author has collected 50 cases of excision at the shoulder-joint for dis- 
ease, 42 of whom recovered and 8 died. Of those tabulated as "recovered," 
2 subsequently died from consumption of the lungs, and 2 were not benefited 
by the operation. These facts increase the mortality to 16 per cent. 
Dr. S. W. Gross analyzed 749 cases of scapulo-humeral excision for shot 
injury, 498 of which recovered and 251 died,-giving a mortality of 33.51 
per cent. Of these excisions, 285 were primary and 379 secondary, with 
143 deaths. 
Dr. Culbertson, in his prize essay entitled "Excision of the Larger Joints 
of the Extremities," analyzes 983 cases of shoulder-joint excision for gunshot 
and other injuries and diseases. Of the 855 excisions executed for gunshot 
wounds, 267 died, or 31 per cent. Of 12 cases in which the operation was 216 
EXCISION OF SPECIAL JOINTS AND BONES. 
done for injuries other than gunshot, 3 died, or 25 per cent. And in 116 
excisions for diseases, 21 proved fatal, or 18 per cent. The result is a total 
mortality of 291, and a mean death-rate of 30 per cent, for the three classes. 
When considered in regard to the period of operation, it appears that when 
the excision was done for gunshot wounds and for injuries during the pri- 
mary period, the death-rate was 25.45 per cent., while in the three classes 
of this author the mortality rate for the secondary operation was 32.66 per 
cent., and for the intermediary period 50 per cent. 
Dr. Otis records 739 excisions of the shoulder-joint done on Union soldiers 
during the late American war, in which the terminations were ascertained, 
with a death-rate of 35.7 per cent. 
The above figures very forcibly point out the superiority of the primary 
and secondary periods for the execution of this operation, and the extreme 
danger of performing it in what is known as the intermediary, or the period 
of traumatic or inflammatory fever. 
Gant has collected from the various civil hospitals in the United Kingdom 
30 cases of excision of the shoulder-joint, exhibiting a death-rate of 1 in 4 
cases, or 25 pei* cent. 
When we compare the mortality attending excision at the scapulo-humeral 
articulation with that attending amputation at this joint, we find that the 
former is considerably greater. The mean mortality of 827 cases of ampu- 
tation analyzed by Otis is 28.5 per cent., whilst the lowest mean recorded for 
excision by any of the authorities is 25 per cent, (except, for disease, by 
Culbertson, 18 per cent.), and the largest, that of Otis, 35 per cent. 
The time required for recovery after decapitation of the humerus varies 
from three to four months, and, although the power to elevate the arm is 
rarely regained, almost every other motion can be performed with facility 
and strength. 
Portions of the clavicle and scapula, along with the upper extremity of 
the humerus, were frequently removed during the War of the Rebellion. 
Forty-two cases of this nature are recorded. In three instances, along with 
the decapitation of the humerus, the acromion and coracoid process, the 
glenoid cavity, and the neck of the scapula were simultaneously removed. 
As the orbit traversed by the humerus includes the region bounded by these 
processes, these cases perhaps stand unparalleled as the most complete ex- 
cisions of the scapulo-humeral articulations on record. Another point worthy 
of particular notice in connection with these 42 cases is the fact that the 
mortality-25 per cent.-was even less than that following excision of the 
head of the humerus alone. 
For the removal of these processes the cutting pliers will be found most 
convenient. 
Excision of the Elbow-Joint.-The conditions demanding excision of this 
articulation are as follows : first, compound luxation, with protrusion of the 
articulating extremity of one or more bones of the joint; second, shot wounds 
of the articulation, attended by extensive comminution ; third, strumous or 
other disease followed by necrosis of the articulating extremities of the bones. 
In cases of suppurating synovitis, even though the joint may be spoiled, 
and though there is no reasonable hope of anchylosis, the operation should 
not be practiced. Should, however, the health of the patient begin to fail 
under the suppuration, and hectic symptoms make their appearance, excision 
should not be withheld. 
The operation has also been advised in cases of anchylosis of the elbow 
when in a vicious position. It will be better, however, under such circum- 
stances, to make a subcutaneous division of the humerus above the condyles 
and establish an artificial joint. 
Operation.-The patient having been etherized, the inner surface of the 
arm should be laid over a pillow rolled into a cylinder, and should be brought 
into a position slightly flexed. EXCISION OF THE ELBOW-JOINT. 
217 
Various incisions for exposing the joint have been proposed. Moreau, 
Butcher, and Syme employ two longitudinal incisions, one on either side of 
the joint, connected in the middle by a transverse cut, resembling the letter 
H. Jaeger and Liston are partial to a T-shaped incision. A simple longitu- 
dinal cut I find to answer every purpose. This plan of exposing the joint was 
first proposed by Park, who was the first to recommend excision of this 
articulation. It is also the plan adopted by Erichsen, Gross, Langenbeck, 
and Maunder. It has the advantage of not severing the triceps muscle from 
its connection with the ulna and the strong anconeus fascia, which blends 
with the posterior surface of the forearm. A longitudinal incision should, 
therefore, be made over the back of the joint, four inches in length, and 
penetrating to the tendon of the triceps muscle, the middle of which cut must 
be over the olecranon process of the ulna. 
The triceps next should be divided to the same extent, down to the bone, 
and, carefully separating the external half with the anconeus muscle and the 
tricipital aponeurosis, the surgeon should have them held by a retractor over 
the external condyle of the humerus. This done, the internal half must 
next be lifted; in doing which the greatest care should be observed not to 
damage the ulnar nerve, lying in the groove between the internal condyle of 
the humerus and the olecranon process of the ulna and covered by a dense 
fibrous membrane. By opening this membrane on a director the nerve will 
be exposed, and can be dislodged from its bed and displaced with the inner 
half of the triceps over the internal condyle of the humerus; the nerve must 
then be held by a blunt hook or a retractor. 
The surgeon, having now exposed the posterior surface of the humerus 
and the olecranon process of the ulna, with a pair of bone pliers cuts away 
the latter from its junction with the shaft of the bone. This accomplished, 
the lateral ligaments of the joint must be severed with a blunt-pointed bis- 
toury, when the ends of the bones can (by flexing the arm, and by the use of 
the elevator and the fingers, peeling away the soft parts) be forced through 
the external wound. 
A flexible spatula or shield is next to be passed between the soft parts, on 
the front of the joint, and the displaced bones, when the saw can be applied 
to the latter without endangering the vessels which are situated anteriorly. 
The amount of bone to be removed must be determined by the extent of 
the disease or injury. When admissible, the excision should include only the 
articulating surface of the humerus, the olecranon as low as the coracoid 
process, and the head and neck of the radius above the tubercle. (Fig. 
1086.) When executed within these limits, the insertion of the brachialis 
anticus muscle, at the root of the 
coracoid process, and that of the 
biceps flexor cubiti, behind the 
tubercle of the radius, will be 
preserved; and these will pre- 
serve to the limb the function of 
flexion. Complete excisions of 
the articulation are supposed to 
be attended with less danger to 
life, and less risk of anchylosis, 
than partial ones,-an opinion 
in which I do not concur when 
the operation is done for disease. 
The statistics drawn from mili- 
tary practice, however, are favorable to complete excisions. I have performed 
the latter with entire success. 
Should the parts, during the operation, be obscured by hemorrhage, a 
tourniquet may be applied over the brachial artery. The Esmarch bandage 
is followed by so much bleeding after its removal that I no longer employ 
it in these operations. 
Fig. 1086. 
Appearance of the bones after excision. 218 
EXCISION OF SPECIAL JOINTS AND BONES. 
In separating the soft parts from the bones, the subperiosteal method may 
be adopted, if the surgeon is anxious to test the bone-regenerative capacity 
of the periosteum. But its value in this direction has, in my judgment, been 
very greatly exaggerated. Not a single dissection, so far as I know, has 
been made which verified the reproduction of the removed portions of bone, 
save that of Mr. Syme, which, however, exhibits only a very good attempt 
to establish a false joint. 
Dressing.-After securing any vessels which may bleed, and thoroughly 
cleansing the joint from all foreign matter with carbolated water, a drainage- 
tube or the oakum seton should be introduced into the wound, and its sides 
united by a few stitches of the interrupted suture. 
The limb is next to be placed at an obtuse angle with the forearm, fixed 
between pronation and supination, in which position a plaster splint is to be 
applied, and the arm placed in a suspension apparatus (Fig. 1087), leaving 
Fig. 1087. 
Plaster splint made by a recurrent roller. 
the wound exposed over the posterior part of the elbow. Over this either 
the antiseptic dressing, or a pledget of lint wet with cold water to which 
has been added a little laudanum, and which can be removed from time to 
time, may be applied. 
After two or three weeks this splint may be laid aside, and the arm be 
placed upon an anterior angular splint having a movable joint. By this 
the position of the limb can be gradually changed to a right angle. After- 
wards, at the interval of every two days, it may be changed by flexion and 
extension, so as to initiate passive movements, and thereby both prevent 
anchylosis and secure a movable bond of union between the ends of the 
bones. 
The value of excision of the elbow articulation may be approximately 
arrived at by considering the statistical data within our reach. 
Dr. Hodges's collection of cases amounted to 119, of which number 15 died, 
or 12 per cent. 
Otis records 627 excisions of the elbow for gunshot wounds, chiefly, though 
a few of them were for caries, resulting from shot injury. Of these excisions 
the terminations were ascertained in 616 cases. Of the 616 there were 142 
who died, making a mortality of 23.05 per cent. This proportion, when 
compared with the death-rate following amputation for the same class of in- 
juries at this joint, shows a mortality of one-tenth of 1 per cent, in favor of 
the latter operation, and about the same as that following amputation of the 
arm, recorded by the same author as 26.7 per cent. Of 138 excisions of 
the elbow for the same injuries (gunshot), done by Confederate surgeons, 81 
recovered, 19 died, and in 38 the termination was not known. Otis tabulates 
588 excisions of this articulation, gleaned from various foreign sources, of EXCISION OF THE ELBOW-JOINT. 
219 
which number 320 recovered, 258 died, and in 9 the results were unknown, 
or a mortality of 43.8 per cent. 
Dr. S. W. Gross has analyzed 499 cases of this excision for shot injuries, 
400 of which recovered and 99 died,-a death-rate of 19.83. 
The period of life at which this excision is performed exercises a great 
influence in determining its success. Of the cases collected by Dr. Gross, 79 
were primary, with 9 deaths (or 11.39 per cent.); and 114 were secondary, 
with 23 deaths (20.13 per cent.); or 8.74 per cent, in favor of primary 
operations. 
Shore has collected 82 cases of this resection. Of 14, in which the opera- 
tion was performed for injuries, 12 recovered, and 2 results were doubtful. 
In 68, done for disease, 40 recovered and 20 died, making a death-rate of 
29.41 per cent., liable to increase could the results of the other 8 cases be 
ascertained. 
The cases of Erichsen and of Bickersteth together number 37, and record 
but 3 deaths. These operations were done for caries of the elbow-joint,-a 
condition which, should it have existed for some length of time, since it so 
changes all the articular components, would have rendered the joints excised 
exceedingly tolerant of cutting operations. Heyfelder and Boeckel have 
collected elbow-joint excisions embracing 145 cases, with 20 deaths and 125 
recoveries; these give a death-rate of 13.10 pei' cent. Hodges has given 
119 similar cases, with 15 deaths (or 12.60 per cent.) and 104 recoveries. 
These five investigators show, in the aggregate, 301 excisions of the elbow- 
joint, with 38 deaths and 263 recoveries. Among the 104 recoveries in Hodges's 
collection are included 15 amputations, rendered necessary by the failure of 
the excision, leaving 89 to be placed to the credit of exsection ; and of this 
last number, 77 (or 86.51 per cent.) are represented as having had useful 
limbs. 
Culbertson tabulates 1075 excisions of the elbow-joint, with 164 deaths, or 
a mortality of 15.25 per cent. Of this total number, 598 were excisions per- 
formed for gunshot wounds, 113 of which proved fatal, or 19 per cent.; 70 
were done for injuries other than gunshot, with 10 deaths, or 15 per cent.; 
377 were executed for disease, with 41 deaths, or 10.87 per cent.; and 13 for 
deformity, with no deaths. 
Gant's collection embraces 211 cases, with 193 recoveries and 23 deaths, or 
12 per cent. Among the recoveries were 1 which required amputation, and 
3 which were twice excised. 
These data are sufficient to place excision of the elbow-joint among the 
established operations of surgery. 
History.-Mr. Park, of Liverpool, first suggested the idea of excising the 
elbow-joint; and, although he never performed the operation, that he con- 
templated its execution is evident from his having, as a preliminary measure, 
cut out this articulation from the dead body. In 1758, Wainman, of Shrip- 
ton, England, had a case of compound luxation of the elbow-joint in which 
the humerus was forced through the wound in the soft parts and some dis- 
tance into the ground. Its lower extremity was sawn off with the olecranon 
fossa. In 1775 a partial excision of this joint was done by Justamond, of 
London, in which the olecranon process with two inches of the ulna was 
excised. The same year a surgeon of Gloucester, Mr. Tyre, cut away the 
lower end of the humerus in a case of compound luxation of the elbow-joint, 
-an operation similar to that which had been done seventeen years previously 
by Wainman. The operation was also performed in 1783, in removing the 
lower end of the humerus for caries. 
The first complete excision, however, was successfully performed on the 
29th of August, 1794, by the elder Moreau, at the Military Hospital of Bar- 
sur-Ornain. The patient was a soldier, who was suffering from caries of 
the bones of the elbow-joint, entailed by an old gunshot wound. In 1797 
the younger Moreau performed a similar operation with success. Not- 
withstanding several of these excisions were performed by the Moreaus, the 220 
EXCISION OF SPECIAL JOINTS AND BONES. 
operation appears to have attracted very little attention in France until 1819, 
when it was again brought before the profession by Roux. 
In England, the first complete excision of the elbow-joint was done in 1818, 
by Stansfield, of Leeds; in Ireland, in 1823, by Crampton, of Dublin; and 
in the same year, in Germany, by Textor. In Scotland, Syme became a 
strong advocate for the operation, performing his first excision in 1828, and 
between this year and 1830 resecting sixteen elbow-joints. In 1831 and 1833 
two complete excisions of the same articulation were done in Scotland,-the 
first by Kerr, of Aberdeen, and the second by Sterling, of Glasgow. 
In the United States, the first excision of the elbow was performed by John 
C. Warren, of Boston, Massachusetts, October 16, 1834, and on the 16th of 
January, 1841, a second was done by Gurdon Buck, of New York. The first 
excision performed in this country for a shot wound of the elbow was done 
by Hoyt, of Hudson, Wisconsin, in 1847, on a soldier, at Jalapa, during the 
Mexican War. 
The history of this important operation is like that of many others in 
surgery: the procedure is forcing its way to professional confidence only after 
many years, and chiefly through the courage of a few brave men who were 
determined to lead whether others would follow or not. It is sad to con- 
sider the sanguinary wars which were waged between 1794 and 1828, and the 
number of arms that were amputated which might have been saved had the 
method of excision received that attention to which it was entitled by the 
success attending the operations of the Moreaus. 
Excision of the Radio-Carpal or Wrist Joint.-The object of excising this 
joint is to preserve the hand. The causes which render the operation neces- 
sary are disease of the articulating ends of the bones, and gunshot or other 
injury. 
By excision of the wrist-joint I mean the removal of the articulating ends 
of the radius and ulna, together with the first row of carpal bones. 
Operation.-In performing the operation, two things are to be observed: 
first, the preservation of the tendons, in front and on the back of the joint, 
intact; and, second, the removal not only of the bones concerned in form- 
ing the articulation (that is, the lower end of the radius and ulna and the 
first row of the carpus), but also of the entire carpus and the articulating 
ends of the metacarpus, if the disease or injury demands it. This operation 
is both a difficult and a tedious one. 
A variety of incisions for exposing the joint have been practiced. That of 
the elder Moreau, who was the first to excise this articulation, was J-shaped, 
while that of Velpeau was quadrilateral. Others have employed an H-shaped 
incision, which must necessarily have been fatal to the future usefulness of 
the tendons. 
The incision which I have employed (after etherizing the patient and ap- 
plying a tourniquet to the arm) consists of two longitudinal cuts (II), one 
on the radial and the other along the ulnar border of the wrist. The first 
should commence one inch and a half above the styloid process of the ulna, 
and should terminate half an inch beyond the carpal extremity of the meta- 
carpal bone of the thumb, passing between the extensors of that bone and of 
the first phalanx of the thumb, on the ulnar side. Care should be taken not 
to divide the radial artery, which lies in the hollow below the styloid process 
of the radius. The second incision is made on the outer side, beginning on a 
level with the prominence of the ulna, and ending half an inch below the 
metacarpal bone of the little finger. 
The soft parts, including all the tendons, must next be dissected carefully 
from the back of the radius and the carpus. 
The radial artery should now be displaced from the radio-carpal fossa, 
drawn downward by means of a retractor, and held out of the way; while 
with a long, narrow, sharp-pointed bistoury passed between the radius and 
ulna and the soft parts in front of the wrist, the surgeon shaves the latter EXCISION OF THE RADIO-CARPAL OR WRIST JOINT. 
221 
from the former, thus opening the wounds on either side of the joint into 
each other. As the knife reaches the carpus, it will become arrested on the 
ulnar side by the pisiform bone, the separation of which from its connection 
with the unciform bone must now be made. Thus the attachment of the 
tendon of the flexor carpi ulnaris is preserved. 
The lateral ligaments being now divided, the radius and the ulna should 
be pushed through the wounds on the outei* and inner side of the wrist, and 
their ends should be cut off on the same level. 
After the removal of the extremities of these bones, the carpus can be 
brought into a position quite accessible to the knife. 
The operator now, with a straight, blunt-pointed bistoury, divides the liga- 
ments, uniting the two rows of the carpus on the dorsal surface. After this 
is done, with one blade of the cutting pliers pressed into the opened joints 
and the other blade applied in front, the upper can be severed from the lower 
row, and extracted, entire or piecemeal, by the bone forceps. 
Should the disease have extended beyond the first row of carpal bones, 
it will be proper to excise the entire carpus, after the plan adopted by Mr. 
Lister. This surgeon advises, in all cases rendering the total excision of the 
joint necessary, that the entire carpus should be removed, together with 
the carpal extremities of the metacarpal bones,-a procedure which I am 
not prepared to accept until a larger experience has established its neces- 
sity. In two cases of wrist excision I did not adopt this plan, and in both 
I obtained an excellent result. 
The method of Mr. Lister consists in making two longitudinal incisions 
along the radial and ulnar borders of the wrist. The first cut must com- 
mence a short distance above the level of the styloid process of the radius 
and over the middle of the back of the radius. At first it is carried towards 
the ulnar side of the metacarpo-phalangeal joint of the thumb, and parallel 
with the course of the extensor secundi internodii pollicis tendon; but on 
reaching the radial side of the metacarpal bone of the index finger it is pro- 
longed downward, along the side of the latter, to a point nearly opposite the 
metacarpo-phalangeal articulation of the thumb. (Fig. 1088.) 
The tendon of the extensor 
secundi internodii pollicis and 
the dorsal branch of the radial 
artery are next to be very care- 
fully detached from the bone on 
the outer side of the incision, 
while on the inner side the ten- 
dons of the extensor carpi ra- 
dialis longior and brevior are to 
be severed from their connec- 
tion with the carpus. 
This done, the next procedure 
is to divide with bone pliers the 
attachments of the trapezium 
to the surrounding pieces of the 
carpus, by which means the latter will be more readily removed. 
The incision on the ulnar side of the joint is next made. This should ex- 
tend from about two inches and a half above the styloid process of the ulna 
to the middle of the metacarpal bone of the little finger. The soft parts 
must now be carefully raised from the back of the wrist and the carpus, by 
keeping the edge of the knife turned towards the bones until the wounds on 
the two sides of the articulation communicate. While this is being effected, 
the tendon of the extensoi' carpi ulnaris will require to be divided close to 
its insertion. 
The operatoi' next proceeds to raise the structures in front of the radius 
and ulna, and also to sever the pisiform and the unciform process of the 
unciform bone,-the latter by means of the cutting pliers. The dissection 
Fig. 1088. 
Lines of excision. 222 
EXCISION OF SPECIAL JOINTS AND BONES. 
should stop short of the deep palmar arch. After dividing the ligaments of 
the carpal bones, the latter must be removed by the bone forceps. 
It remains to cut away next the articular ends of the radius and the 
ulna. This is readily done by turning first one and then the other out of the 
lateral wounds, and applying to them the saw. The ulna should be excised 
above its articulation with the radius; and the radius, when the disease or 
the injury will allow, should be excised sufficiently low not to disengage too 
much the tendons from its grooves. Under all circumstances, however, the 
two bones should be removed on the same 
level, otherwise it will be difficult to pre- 
vent permanent adduction of the hand. 
The carpal or cartilaginous ends of the 
metacarpal bones are now to be removed 
with the cutting pliers, turning them out 
of one or other of the lateral wounds, as 
may be found most convenient. 
The trapezium, having been previously 
separated from the other bones of the 
carpus, is next to be dissected out, and so 
also the end of the metacarpal bone of the 
thumb, taking care not to injure either 
the flexor carpi radialis or the radial 
artery, which lies close to the tendon of 
this muscle. 
Last, the articular surface of the pisi- 
form bone is to be removed, and the hooked 
process of the unciform likewise. Fig. 
1089 (from Lister) supplies a diagram- 
matic view of the structures involved in 
the operation of Mr. Lister. 
Dressing.-A drainage-tube, or a twist 
of oakum previously treated by carbolic 
acid, should now be passed across the 
wound from side to side, the edges of the 
incision stitched together, and the hand 
and forearm placed over a splint well padded. This should be provided 
with convex pieces of cork or pine wood fastened to the palmar part of the 
splint, over which the palm of the hand and the thumb, covered by a water 
or a carbolated dressing, are to rest, and to which they are to be bandaged 
by the turns of a roller. (Fig. 1090.) 
During the subsequent treatment, passive motion of the fingers and thumb 
Fig. 1089. 
.<4, radial artery; B, tendon of the extensor of 
the second phalanx of the thumb; C, extensor 
indicis; D, extensor digitorum communis; E, 
extensor minimi digiti; F, extensor of the first 
phalanx of the thumb; IIand I, extensor carpi 
radialis longior and brevior; X, extensor carpi 
ulnaris; L L, line of incision on the radial side 
of the wrist and hand. 
Fig. 1090. 
Splint applied after excision of the wrist. 
and metacarpus must be kept up, in order to prevent any tendinous or bony 
adhesions, which might destroy the usefulness of the hand. 
The complex nature of the wrist and carpus, together with their numerous 
blood-vessels, tendons, and bursal and synovial membranes, must necessarily 
render excision a difficult and embarrassing operation, which, in view of the 
deformed and helpless state in which recovery often leaves the hand, tends 
to excite doubts in the minds of many as to its propriety. With reference EXCISION OF THE RADIO-CARPAL OR WRIST JOINT. 
223 
to the first difficulty,-that of executing the operation,-patience, caution, 
and skill can surmount every obstacle. As to the second objection, it may 
be said that the preservation of the hand, even if its functions are badly 
discharged, is vastly to be preferred to its entire removal. 
Another and a much more important matter to be considered in resolving 
the question is the risk to life as compared with other plans of treatment. 
Hodges tabulates 31 cases of wrist-joint excisions with known terminations. 
Of this number 6 died,-a death-rate of 19.35 per cent.; 8 required subsequent 
amputation; and 14 recovered. Dr. S. W. Gross has collected and analyzed 
43 cases of this excision, performed on account of shot injuries, with 36 
recoveries and 7 deaths,-or a death-rate of 16.28 per cent. The mortality, 
both in Hodges's and in Gross's collection, is considerably greater than that 
after amputation of the forearm, which is a trifle over 12 per cent. Mr. 
Listei' has reported 15 cases of excision of the wrist articulation, with 3 
deaths, or 20 per cent. 
Otis, in his analysis of excisions for shot injury of this joint, has collected 
96 operations, followed by 81 recoveries and 15 deaths, or a mortality of 
15.62 per cent. But among the recoveries there were 9 amputations. Only 
6, however, of the 96 cases were examples of total excision, 5 of whom re- 
covered and 1 died,-a death-rate of 16.66 per cent. The condition of the 
hand after recovery is mentioned in 59 instances,-"51 had anchyloses at 
the wrists; 5 mobility with deformity; and 3 dangling joints." 
Gant has recorded from different sources 32 cases, with 26 recoveries and 
6 deaths, or 1 in 5J. 
When it is considered that in many of these cases the operation consisted 
in removing one or more bones of the carpus, or the extremity of the radius 
or the ulna, it is evident that.these statistics can only be made proximately 
available in determining the value of wrist excisions in the proper sense of 
that term. 
In comparing the results of excisions of the wrist-joint with those of am- 
putations at the same joint, and with amputations of the forearm, we find that 
of the former (that is, amputations through the radio-carpal articulation) 
there were 68 operations with 7 deaths, or a death-rate of 10.29; and that 
of amputation through the forearm there were reported 1747 operations, 
with a mortality of 13.9 per cent.,-a gain in favor of amputation over excision 
of 6.45 per cent. 
If now we compare the mortality attending excisions and amputations 
done at the most favorable time, namely, the primary period, it will be found 
that the death-rate for the former was 10.29, while for the latter it was only 
9.6 per cent. 
Professor Culbertson has tabulated 182 cases of wrist-joint excisions, partial 
and complete. These include operations done for gunshot wounds, for inju- 
ries othei' than gunshot, and for disease. For the 70 cases embraced in the 
first class the mortality rate was 15.87 per cent.; for the second class, 16 in 
number, 50 per cent.; and for the third class, 92 in number, 13.66 per cent.; 
or for all classes together, 29.84 per cent. Twenty-four of the 182 cases are 
recorded as total or complete excisions. All the rest, as far as determined, 
were partial. 
In estimating the comparative mortality attending the partial and the com- 
plete excisions in the different classes, the same author states that following 
the partial excisions for shot wounds there were no deaths, while in those 
which were total the death-rate was 20 per 100. For injuries other than 
shot wounds the mortality was 50 per cent, for partial excisions,-the only 
operations that were done in this class. And in those operations executed 
for disease the death-rate for partial excisions was 20 per 100, while for com- 
plete excisions it amounted to only 8 per 100. 
Upon analyzing the data furnished by the different writers who have been 
quoted, it will be found that the results of excisions for the same class of in- 
juries or diseases, so far as the comparison can be made, do not materially differ. 224 
EXCISION OF SPECIAL JOINTS AND BONES. 
The statistics of wrist-joint excision furnished by the late American war 
are sufficiently large to aid us in determining approximately the value of 
this operation as a conservative measure in shot injuries. When it is con- 
trasted with the treatment of this class of injuries by the expectant plan, by 
amputation through the radio-carpal articulation, and by amputation of the 
forearm, we obtain the following results: 
Shot wounds treated by excision yielded a mortality of 15.6 per cent.; by 
expectancy, 7.6 per cent.; by amputation through the joint, 10.6 per cent.; 
and by amputation through the forearm, 9.6 per cent. This showing is de- 
cidedly against excision, though the numerical disparity between the cases 
treated by these different measures must not be overlooked. 
In view, however, of the exceptional skill necessary for the proper execu- 
tion of this operation, and the subsequent transportation of the patients 
from temporary to permanent hospitals, often over very considerable dis- 
tances and attended with more or less personal exposure,-all conducing to 
inflammatory accidents,-to which may be added the disadvantages of a 
change of medical attendants, I have no hesitation in saying that excision of 
the wrist-joint for shot injuries must have a very limited application. On 
the other hand, in cases of disease where the alternative lies between ex- 
cision and amputation, if the necessary skill can be commanded for its 
performance, and all the indispensable arrangements are at hand for con- 
ducting the details of the subsequent treatment, and, not the least important, 
if the patient is not past the period of adult life, is free from any serious 
organic disease, and is not broken down in health, excision should be ac- 
cepted without hesitation, as in the event of failure the chances of recovery 
by amputation are not lessened. 
History.-In a case published in 1756, Bagieu, in a shot wound of the 
wrist, removed the carpal extremities of both the radius and the ulna,-the 
first recorded example of a partial excision of this articulation. 
Cooper, of Bungay, in 1758, in a case of compound luxation of the wrist, 
cut away the lower end of the radius which projected through the external 
wound. The patient was young, and recovered without having either the 
mobility or the strength of the articulation materially affected. 
About the year 1772, Dr. Ored, of Chester, excised three inches of the 
lower end of the ulna in a young man for disease. Some doubt has been ex- 
pressed whether this was an excision, as the phraseology used seems to imply 
that the operation was done in the continuity and not in the contiguity of 
the bone. Birnbaum, a French military surgeon, in 1759 removed by excision 
a number of pieces of bone from the wrist of a soldier. 
Moreau the younger in 1794 excised the radio-carpal articulation of a seam- 
stress, with a good result. About 1823, Verbeeck removed the lower end of 
the radius in a lad fourteen years of age, with a recovery. Roux in 1830 cut 
away the articular extremity of both the radius and the ulna; and in 1834 
Jaeger excised the lower end of the ulna for a shot wound. The operation 
in the latter case failed, after which the forearm was amputated, the patient 
not recovering. 
After the last-named date these operations became more common, being 
executed in France by Roux, Maisonneuve, and others; in England by Fer- 
gusson, Erichsen, Stanly, Butcher, and Hancock; and in Germany by Lang- 
enbeck, Baucken, Kuster, and other surgeons. 
Excisions of Portions of Bones of the Hand.-The excisions practiced on 
the bones of the hand are carpal, metacarpal, and phalangeal. The impor- 
tance of the hand as a prehensile, tactile, and defensive mechanism is so 
great that in no other part of the body does there exist so much necessity 
for conservative surgery. In general it may be said that in all operations 
upon this member the utmost care should be observed to sacrifice no portion 
which it is possible to preserve. When the alternative is presented of sacri- 
ficing either symmetry or function, the former must yield to the latter, though EXCISIONS OF PORTIONS OF BONES OF THE HAND. 
225 
all operations should as far as possible proceed upon the principle of pre- 
serving both. 
At the same time it does not answer to adhere too rigorously to the 
maxims of preservation. For example, when the proximal or intermediary 
phalanges are disorganized by disease or by injury, it would be a useless pro- 
cedure to attempt their excision, as the remaining ungual phalanx and the 
mass of soft parts would be worse than functionless,-rather an incumbrance 
or obstruction to the use of the remaining parts of the member. Amputa- 
tion under these circumstances is to be preferred. 
When, however, the distal or ungual phalanx has been destroyed by acci- 
dent, or by whitlow or other disease, its excision should be practiced, as the 
remaining soft parts, having the second phalanx to rest against, will still 
serve to prolong the digit. In the flexion and extension of the fingers consists 
their usefulness; and therefore as far as possible these functions must be 
preserved,-especially the flexion and extension of the proximal phalanx, 
which if saved will in a good degree compensate for the loss of the same 
movements in the second and last phalanges, as the last two must follow the 
movements of the first. 
Operation.-If the cause demanding an operation is confined to the meta- 
carpal extremity of a phalanx, its excision will be proper. This may be done 
by a longitudinal dorsal incision commencing over the lower end of the cor- 
responding metacarpal bone, and prolonged to the extent of an inch over 
the phalanx and made parallel with the edge of the extensor tendon. This 
last should be carefully raised without being cut, and pressed to one side out 
of the way of injury. 
The disarticulation being effected by the division of the connecting liga- 
ments, chiefly the lateral, the diseased extremity can be readily clipped away 
by the bone pliers. 
The after-dressing consists in placing the hand on a palmar splint with a 
conical padding, so as to allow the diseased as well as the other fingers to 
be preserved in a slightly flexed position. After covering the part with a 
piece of lint wet with water or moistened with carbolic acid and sweet oil, 
the hand and forearm should be bound to the splint loosely with a roller. 
When the ungual phalanx requires resection, it may be done either by a 
longitudinal incision made over its palmar surface or by one carried trans- 
versely across the end of the finger. In the first the soft parts should be 
dissected away from the bone laterally; in the second, they should be sepa- 
rated from before backward, until the disarticulation can be effected. In 
either event the knife should be kept close upon the bone. 
After the denudation of the bone the disjunction can be facilitated by 
seizing the piece with a pair of bone forceps and twisting it in different 
directions, while the ligaments which unite it to the adjoining phalanx 
are divided by the knife. The dressing afterwards required is a palmar 
splint, as in the operation previously described. 
The thumb.-The functional importance of the thumb to the usefulness of 
the other part of the hand is so great that its loss is a grave calamity, and 
one which no prosthetic contrivance can remedy. 
No part, therefore, of this portion of the member should be unnecessarily 
destroyed. Even if it should be saved at the expense of all motion, remain- 
ing permanently stiff and constrained, its value cannot be over-estimated. 
Excision of its metacarpo-phalangeal joint, or of a part, or even the whole, of 
its metacarpal bone, may be done without destroying its usefulness. 
The metacarpal bones not unfrequently require excision in consequence of 
disease or injury. 
The excision of that of the thumb requires a longitudinal incision made 
exactly in the line of junction between the dorsal and palmar skin. The 
muscular cushion on the inner surface, and the extensor tendons on the outer, 
must be raised by keeping the knife directly in contact with the bone, thus 
preventing hemorrhage as well as preserving the structure. After the bone 
VOL. II. -15 226 
EXCISION OF SPECIAL JOINTS AND BONES. 
has been isolated, it must be disarticulated from its proximal phalanx; or, 
if the condition of the metacarpal bone will allow, it may be severed by the 
cutting pliers a short distance back. After this is done it must be drawn 
out of the external wound and dissected from all its surrounding connections 
back to the trapezium, from which it can be detached by a few touches of 
the knife. 
The remaining portion of the thumb, having lost much of its support, 
should be bound to a splint of binders' board, moulded neatly to its palmar 
surface, and so retained until consolidation has taken place. 
In exsecting the other metacarpal bones the incision should be longitu- 
dinal, and made over the dorsal aspect of the bone in such a manner as to 
avoid the extensor tendons. 
By keeping the edge of the knife against the piece to be removed, it is not 
difficult to separate it from the surrounding parts. Then it can be removed 
by disarticulating it first from the metacarpus, or by seizing it neai' to this 
joint with the cutting pliers, when the disease will allow, and, after drawing 
it out, dissecting it towards its phalangeal articulation. From this it must 
be separated; or, if not disorganized to this extent, it must be cut off in the 
manner directed for removing its carpal extremity. 
Whenever it is possible, the periosteum should be preserved in these opera- 
tions, as a certain amount of new bone will be formed, which, though it may 
be a mere caricature of the original piece, will aid very much in establishing 
a line of resisting tissue for the support of the finger. 
In caries or necrosis this membrane is often found considerably thickened, 
and its separation is by no means difficult. 
Metacarpus.-Excisions of individual pieces of the metacarpus may be re- 
quired in compound luxation or in disease. And, as in similar operations 
upon the metacarpus, the bone or bones must be exposed on the dorsal sur- 
face of the hand, the operator exercising the same care with reference to the 
superincumbent tendons as in the other operations. 
After exposure the piece may be dealt with either by the gouge or by the 
knife and forceps. In my own experience these operations on the carpus 
have never proved satisfactory. 
Excision of the Sternum.-Partial operations of this nature have been done 
for gunshot injury, for abscess in the anterior mediastinum, for caries, and 
for the extraction of foreign bodies. Ileyfelder has collected 17 cases of 
partial excision of this bone, with a single death. I have removed, from a 
patient in the Philadelphia Hospital, a portion of the gladiolus, for evacuating, 
as I supposed, an abscess of the anterior mediastinum. Though no pus was 
discovered, the sternum was found in a state of caries. No evil effects fol- 
lowed the operation. In one instance, Linoli, in consequence of great dis- 
tress and vomiting (caused by the contact of the inverted ensiform cartilage 
with the surface of the stomach when the latter was distended), excised the 
appendage with entire relief of the symptoms. Assistant Surgeon McGill, 
during the War of the Rebellion, in the case of a sergeant wounded at Peters- 
burg, Virginia, by a conoidal ball, after extracting the broken fragments of 
the sternum, observed the pulsations of the heart,-the latter organ being 
extensively exposed. 
The sternum is rarely the subject of necrosis, though it is frequently at- 
tacked by caries, especially that of a syphilitic nature. As its formation is 
almost wholly spongy, the tendency of the disease is to extend throughout 
the structure of the bone. No operation, therefore, should be undertaken 
for disease unless the indications for its performance are very clearly estab- 
lished. 
The statistical details of these excisions are far from being satisfactory,- 
indeed, are open to very just criticism. When the sternum is comminuted, 
from shot or injury, the extraction of loose pieces will always be proper. 
When no constitutional vice of a syphilitic or tubercular nature is present EXCISION OF THE RIBS AND THEIR CARTILAGES. 
227 
in the system, fractures of this bone usually do well. The records of the 
late American war furnish 51 cases of gunshot fracture of the sternum, with 
18 deaths, or a mortality of 35.3 per cent., the fatality being largely due to 
concomitant injuries sustained by the contents of the chest. 
When a formal excision of a part of the sternum is demanded, the bone 
may be exposed by a longitudinal, crucial, or semilunar incision, and the 
affected part cut out with the trephine, the gouge, or a Hey's saw. 
Excision of the Ribs and their Cartilages.-Excision of the ribs is an opera- 
tion rarely demanded. The causes for which such interference has been 
deemed necessary are caries, necrosis, carcinoma, enchondroma, and gunshot 
injury. Necrosis as compared with caries of the ribs is exceedingly rare. 
I have met with several cases of caries of the ribs or of their cartilages, 
occurring as a sequel of typhoid fever, and in one instance resected por- 
tions of the cartilages of the seventh and eighth. In other cases, where the 
patients were treated on the expectant plan, recovery, though slow, event- 
ually took place: so that, unless there be conclusive evidence of a necrosed 
fragment, giving rise to inflammatory irritation of the pleura beneath, or the 
disorganization of a considerable portion of a rib, I believe it is safer to 
leave the separation and expulsion of the affected part to natural processes. 
When, however, a marked growth on the side of the chest is developed, and 
the ribs become involved in the disease, excision will be proper, provided the 
general system does not exhibit marks of a malignant dyscrasia. In gunshot 
wounds attended by comminution of a rib, the loose fragments should be 
extracted. 
Operation.-When the operation is performed for caries, an incision should 
be made directly over the diseased rib and parallel with its course. After 
dividing the tissues down to the bone, the periosteum should be incised, and, 
by means of an elevator, carefully separated from its connection with the 
rib,-first on its external and afterwards on its inner surface. 
In both caries and necrosis this is not difficult to accomplish, as the mem- 
brane is usually greatly thickened by inflammatory agencies. By keeping 
in close contact with the rib, the pleura and the intercostal vessels can be 
detached without risk to either. It is otherwise, however, when the opera- 
tion is undertaken for tumors implicating these bones; here the danger to 
the pleura is very great, and its separation without lesion requires the 
greatest patience and care. 
The incisions in such cases should be elliptical, or of any other shape that 
will give the freest exposure of the parts. 
When the rib is once isolated, it may be divided in different ways. A chain- 
saw may be carried beneath it, and made to cut from within outward; or, 
a piece of leather or wood having been passed between the bone and the 
pleura to protect the parts, the division may be effected by a metacarpal saw; 
or, finally, it may be done by the cutting pliers. 
As soon as the section has been made, the rib should be drawn forward, 
when it can more satisfactorily be peeled off from its subjacent connections, 
by means of the elevator, to the extent necessary. It can then be again 
severed by the pliers or saw and the segment removed. 
The dressing consists (after any vessels requiring ligature have been tied) 
in bringing the edges of the wound together by the interrupted suture, and 
giving additional support by a compress, held in place either by adhesive 
strips or by a broad bandage surrounding the chest. 
History.-Excision of the ribs is one of the most ancient operations in sur- 
gery. At least we are led to this conclusion by the frequent allusions made 
to the subject in the works of Celsus, Galen, Severinus, and others. Velpeau 
records an operation of this nature by Suif, in which the surgeon, after re- 
secting two ribs and leaving an opening into which the hand could be thrust, 
removed a large portion of the right lung. Portions of the cartilages were 
resected by Moreau, Jaeger, and Kuchler. Richerand excised portions of 228 
EXCISION OF SPECIAL JOINTS AND BONES. 
four ribs, and with them a considerable amount of the thickened pleura, ex- 
posing to the eye the pulsations of the heart.* Dr. W. A. McDowell, of Vir- 
ginia, receives the credit of having been the first in this country to remove 
extensive portions of the ribs.f This surgeon excised the greater portion 
of the sixth and seventh ribs on account of necrosis. Dr. M. Antony, of 
Georgia, in one instance exsected the fifth and sixth ribs for caries, and at the 
same time removed a large portion of the right lung.£ Warren, of Boston, in 
1836, and again in 1837, executed an extensive operation on the ribs, in the 
first instance for the removal of an enchondroma, and in the second for an 
osteosarcoma growing from the side of the thorax.§ Three inches of the 
seventh and two inches of the sixth rib were excised in the first case along 
with the tumor; and in the last a part of the ninth rib, with its cartilage. 
Both patients recovered. 
Dixon cut away the tenth costal cartilage, which had, by an accident, become 
separated from its rib, and, by irritating a contiguous nerve, occasioned a 
severe neuralgia. The patient recovered from the operation, and also from the 
pain. 
Roux excised four inches of the fifth rib for necrosis, at the same time 
evacuating a considerable amount of pus which was confined between the 
bone and the pleura. This patient died from pleuritis.|| George McClellan, 
in 1842, in a patient suffering from spina ventosa, resected the sixth and 
seventh ribs almost from the cartilages to their vertebral 
Death ensued nine weeks after the operation from what was regarded as 
bilious remittent fever. The same surgeon had previously, on several occa- 
sions, excised portions of the ribs for morbid growths and for caries. Pro- 
fessor Gibson also executed an extensive resection of portions of two ribs for 
a malignant disease. Professor Gross, in 1857, successfully removed the 
central portions of the fifth and sixth ribs on account of scrofulous disease.** 
The pulsations of the heart were exposed at the bottom of the wound. Iley- 
felder studied the history of 37 cases of excision of parts of the ribs, all of 
which recovered except 8. 
Excision of the Hip-Joint.-Excisions of the coxo-femoral articulation may 
be required in consequence of shot or other injury, and fbr caries or necrosis 
following hip-joint disease. Such operations, however, rarely contemplate 
more than the decapitation of the femur, or the removal, at most, of the head 
and neck of the bone, and of the trochanter major. In cases where the 
acetabulum is found necrosed, it is, nevertheless, highly proper that the dis- 
eased portions should be cut away with the gouge, scraper, and forceps. 
Operation.-Incisions of various forms have been practiced for exposing 
the articulation by different operators. Thus, we have the longitudinal, I; the 
curvilinear,; the crucial, -4-: the semilunar, z \; the V-shaped; 
and the T-shaped. The first or longitudinal incision is that proposed by 
White,-who originally suggested the operation. This, or one somewhat 
resembling the italic f, which I prefer, answers every purpose. (Fig. 1091.) 
The patient, having been put under the influence of an anaesthetic, should 
be placed on the sound side. The surgeon now feels for the great trochanter, 
and, commencing one inch and a half above its summit, makes a curvilinear 
incision down along the posterior border of the process, terminating about 
two inches below its base, and making a wound from five to six inches in 
length. 
The knife should now divide all the tissues down to the bone, including the 
periosteum, and to the extent of the first incision. At this stage of the 
* Medical Repertory, New York, 1818, vol. iv. p. 401. 
f American Medical Recorder, 1827, vol. xiii. 
| Philadelphia Journal of Medical and Physical Sciences, vol. vi. p. 108. 
3 Boston Medical and Surgical Journal, 1837, vol. xvi. p. 201. 
II Chelius's Surgery, vol. iii. p. 767. 
McClellan's Surgery, p. 352. 
*« Gross's Surgery, vol. ii. p. 1080, 5th edit. EXCISION OF THE HIP-J01 NT. 
229 
operation it is advised by Sayre to cut through the periosteum at right angles 
with and about the middle of the first wound, and then, by means of an 
elevator, carefully to detach this membrane from 
its connection with the bone, together with its 
tendinous attachments. When the periosteum 
is found thickened, this is not a difficult task; 
but if not thickened, its separation in any de- 
gree of entirety is scarcely feasible, and need 
not be attempted. 
The sides of the wound being held apart by 
means of retractors, the tendons of the external 
rotator muscles are to be divided with a blunt- 
pointed bistoury; this must be done at their 
insertion in the trochanteric fossa. 
With a finger introduced into the wound, 
any remaining shreds of tissue adhering to the 
bone should now be separated, and the head of 
the femur should be located by the touch (the 
certainty of which may be established by ro- 
tating the limb at the same time, when the 
head of the femur may be felt under the digit). 
The next step consists in dividing the cap- 
sular ligament, which should be done on its 
anterior and lower part with the probe-pointed 
knife, and wThile the thigh is carried a little back- 
ward in order to render this ligament tense. 
This accomplished, the limb must be adducted,-that is, carried across its 
fellow,-when the head of the bone will start out of its socket and appear in 
the external wound. The ligamentum teres may then be conveniently severed. 
When the neck of the femur is in a state of caries, some care must be 
exercised in forcing the bone outward, as if too strong adduction is made it 
may readily, on account of its brittleness, be broken. 
Two plans are pursued in dividing and extracting the articular end of the 
bone. In one the section is made by a chain-saw, passed beneath the femur 
and without displacing the latter, after which the diseased piece is seized 
wTith a pair of forceps, drawn forward into 
the wound, and its acetabular connections 
severed by touches with the blunt-pointed 
knife. In the other plan, the head and neck 
of the bone, after being freed from the re- 
straint of the capsular and round ligaments, 
are, by abducting the limb, thrust through the 
external incision; and, after interposing be- 
tween them and the bone and the soft parts 
a wooden or other spatula, they are sawed 
through from without inward. (Fig. 1092.) 
The amount of bone to be removed must 
be determined by the extent of the disease 
or injury. Under any circumstances the 
whole of the trochanter major should be ex- 
cised, leaving the trochanter minor intact. 
(Fig. 1093.) 
If any part of the great trochanter is 
allowed to remain, it will prove a source of 
mischief, not only by projecting into the 
wound, but also by obstructing the free escape 
of the discharges. 
By leaving the trochanter minor untouched, the insertions of the psoas 
magnus and iliacus interims muscles remain undisturbed. 
Fig. 1091. 
Line of incision. 
Fig. 1092. 
Head and neck of the femur displaced,- 
with the spatula beneath, preparatory to 
applying the saw. 230 
EXCISION OF SPECIAL JOINTS AND BONES. 
After decapitation of the femur the finger should be passed through the 
wound into the acetabulum. If this cavity is found to be involved in the 
disease, the gouge, scraper, and bone for- 
ceps will usually serve to remove the dis- 
eased portions. The entire floor of the ace- 
tabulum may be excised without exposing 
the cavity of the pelvis, as the internal peri- 
osteum and the obturator fascia serve to 
establish a secure barrier against intra-pelvic 
infiltration. 
The excision having been accomplished, 
the bleeding arrested, and all foreign matter 
removed, a seton of oakum, or a rubber 
drainage-tube, must be carried down to the 
bottom of the wrnund. The sides of the 
wound are now to be supported by ad- 
hesive strips, but not brought together. 
If the operator has been fortunate enough to preserve the periosteum, it 
should be lightly stuffed with the oakum, in order to preserve its form and 
to favor an orderly reproduction of new bone. 
The wound being now covered with some lint moistened with carbolized 
oil and retained in position by a few adhesive strips, the limb should be placed 
in the extended position, a little abducted, in order to 
prevent the upper end of the bone from entering the 
wound, and extension should be made by means of 
a weight suspended from the leg and thigh with ad- 
hesive plasters. Lateral pressure will also be required ; 
and this can be effectually supplied by sand-bags placed 
along the outer and inner aspects of the limb. 
Dressing.-When the excision has been performed 
for a destructive caries following coxalgia, the wire 
breeches, or cuirass (Fig. 1094), employed by Professor 
Sayre, constitutes an excellent dressing. This appa- 
ratus is constructed of wire, and has very much the 
shape of the human figure. After the apparatus has 
been well padded, the patient is placed in it. The foot 
of the sound limb is first secured to the foot-piece, 
which has been previously well padded both on its 
plantar and dorsal surfaces. A roller is now passed 
around the foot and foot-piece and continued up to the 
knee. Over the knee are placed some cotton and a 
splint of pasteboard, or several layers of stout paper, 
when the bandage is continued to the pelvis, and 
completed by several spicas of the groin. 
Along the sides of the affected limb are placed ad- 
hesive plasters extending as high as the lower end of 
the wound, and running some distance below the foot. 
These plasters must be secured by a smoothly-applied 
roller, and, after padding the foot, their free ends are 
to be carried about the movable foot-piece, when, by 
turning a screw attached to the latter, the requisite 
degree of extension is made. 
After the limb is brought into the desired position, 
a roller is carried from the foot to the groin, securing 
it to the cuirass, and, as on the sound side, ending by 
a spica including the thigh and the pelvis. The dress- 
ing to absorb the discharges from the wound can be 
readily applied through the large oval fenestra in the wire over the hip. 
When the subject of the excision is over ten years of age, the dressing 
Fig. 1093. 
Sectiou of the upper end of the femur on a 
level with the base of the great trochanter. 
Fig. 1094. 
Wire breeches, or cuirass. EXCISION OF THE HIP-JOINT. 
231 
ordinarily used for fracture of the thigh will answer every purpose, with the 
addition of a long outside splint, bracketed at the hip, or, what will serve 
the same object, a long sand-bag for the outside of the limb and body, and 
a short one for the inner aspect of the thigh and leg. 
The conditions demanding resection of the hip-joint on account of disease 
have been already discussed under the head of coxalgia, to which the reader 
is referred. 
The results of these excisions in military practice have been very carefully 
analyzed by Dr. Otis. Previous to 1861 there had been only 12 cases of this 
operation for shot wounds, all of which save one proved fatal, and during and 
after the War of the Rebellion 73 excisions of the hip were executed; making 
a total of 85 cases. Of this number 39 were primary, 33 intermediary, and 
13 secondary operations. 
Of the 39 primary, 36 died and 3 recovered,-a death-rate of 92.30 per 
cent.; of the 33 intermediary, 30 died and 3 recovered,-a death-rate of 90.9 
per cent.; and of the 13 secondary, 11 died and 2 recovered; in all there 
were 77 deaths and 8 recoveries, or an average mortality of about 90.6 per 
cent. This result presents a gloomy and, at first sight, a very discouraging 
exhibit for excision of the hip-joint fbr shot injury; but, to see the subject in 
a just light, these figures must be compared with the results following the 
alternatives of this operation, namely, amputation at the hip-joint and the 
treatment by expectancy. 
Dr. Otis has tabulated 183 amputations at the hip-joint, of which 79 were 
primary, 76 intermediary, 20 secondary, and 8 re-amputations. Of the 79 
primary, 75 died, 1 recovered, and 3 were undecided,-a mortality of 94.93 per 
cent.; of the 76 intermediary, 70 died and 6 recovered,-a death-rate of 92.10 
per cent.; of the 20 secondary, 13 died and 7 recovered,-a mortality of 65 
per cent.; and of the 8 re-amputations, 4 died and 4 recovered,-a mortality 
of 50 per cent.; giving for the entire 183 operations 162 deaths, 18 recoveries, 
and 3 doubtful results, or a death-rate of nearly 90 per cent. 
In 122 cases treated on the expectant plan, or by temporization, only 8 cases 
of recovery are recorded, leaving a mortality of 93.4 per cent. 
We have, accordingly, a mortality of 90.6 per cent, for coxo-femoral ex- 
cision ; nearly 90 per cent, for amputation; and 93.4 per cent, for expectancy, 
-an exhibit slightly in favor of amputation. 
Mr. Holmes tabulates his own 19 cases of excision of the hip for disease in 
children: 6 died from the direct effects of the operation ; 1 died after the 
operation from previous effects of the disease; 1 died of independent disease; 
2 recovered from the disease, but died a long time afterwards; 2 were little, 
if at all, benefited; 1 (twice excised) was doubtful; 3 had useful limbs, but 
with sinuses; and 3 recovered completely. 
Of Dr. Hodges's 111 cases, 50 recovered, or 45 per cent. Gay gives 4 cases, 
with 3 recoveries and 1 death.* Ashhurst refers to 400 cases, in which the 
mortality was about 50 per cent. Of M. Good's 112 reported coxo-femoral 
resections, 52 were attended with success, and 60 were fatal,-a mortality of 
53.57 per cent.f Of Dr. Sayre's 59 cases of exsection of the hip-joint for 
coxalgia, as tabulated by himself, 39 recovered permanently; 8 who had re- 
covered from the operation died of disease entirely foreign to the operation; 
4 died of acute intercurrent disease, and 8 from the exhausting effects of hip 
disease. 
The fallacy, however, of attempting any absolute deductions from the 
military statistics which have formed the basis of the preceding conclusions 
has not escaped the attention of the critical mind of the surgical historian of 
the war, who intimates that, in all probability, all the successful cases of coxo- 
femoral amputations have been recorded, while, most likely, a number of the 
fatal cases have not been published; and, again, that secondary coxo-femoral 
amputations and re-amputations, where the primary injury was received low 
* Lancet, September 15 and 22, 1872. 
f Gazette des HSpitaux. 232 
EXCISION OF SPECIAL JOINTS AND BONES. 
down in the thigh, cannot fairly be compared with excision or temporization 
in cases where the original lesion was in the hip-joint. At the same time, in 
order that the operation by amputation should not be unfairly dealt with, he 
admits that the worst cases were subjected to this procedure. Again, the 
excisions are to be credited with many cases in which, in consequence of 
other lesions independent of those implicating the hip-joint, the results must 
necessarily have proved fatal. 
No operation in surgery more imperatively demands, as a condition of suc- 
cess, immobility of parts than that of excision of an articulation. In a very 
large portion of the cases reported this was impossible, as the patients were 
transported after the operation over considerable distances; and even when 
in a permanent hospital they lacked the systematic application of toe most 
effectual appliances for enforcing rest. 
The statistics of the expectant plan, showing a mortality of 93.4 per cent., 
are sufficient on their face to give them no standing in court, and are exceed- 
ingly vulnerable to criticism in another point of view,-that of diagnosis. 
Except where the fact has been established by a digital exploration, it is very 
difficult to pronounce with certainty as to the existence of articular lesion. 
And there is abundant evidence to show that in some of the cases reported 
as recoveries after articular lesions no such injuries existed. 
Culbertson has collected from various sources 121 cases of excision for 
shot injury at the hip-joint, with 106 deaths (or a death-rate of 87.6 per cent.), 
13 recoveries, and 2 doubtful,-a result varying but little from that deduced 
from the compilations of Otis. 
The question, then, as to the treatment of shot wounds of the hip-joint is 
really narrowed down to a choice between excision and amputation. 
It is impossible to conceive that the skillful decapitation of the femur, if 
followed by immobility of the parts and free drainage, can prove so hazard- 
ous to life as the dissevering of the entire member from the trunk. In 
general it may be said that primary excision of the upper extremity of the 
femur will be indicated in all cases of shot injury of the articular extremity of 
the bone in which no other serious complication exists,-a statement which 
would remand to the domain of amputation all cases in which, in addition 
to a coxo-femoral fracture, there is a wound of the femoral blood-vessels, 
or a great destruction of the soft parts at the upper part of the thigh, or a 
multiple fracture of the thigh, or a comminution or splintering of the femur 
for several inches below the trochanter. 
Three other conditions may also be stated as demanding amputation, even 
when the joint is not implicated : 
First. When the femoral blood-vessels have been severed,-in which case 
the limb, if allowed to remain, must fall into a state of mortification. 
Second. When the extremity is carried away by a cannon-shot, or when 
the femur is broken and the soft parts are torn away from the thigh so near 
to the pelvis that room is not left sufficient to obtain a flap without an ex- 
articulation of the bone. 
Third. Amputation will also be demanded in the event of osteo-myelitis 
extending to the neck of the bone. 
History of Hip-Joint Excisions.-Excision of the head of the femur was 
suggested as early as 1769, by Charles Wffiite, of Manchester; the feasibility 
of which he had previously demonstrated upon the cadaver. It was not, 
however, until 1822 that it was performed on the living subject, when Mr. 
Anthony White, Surgeon to the Westminster Hospital, London, successfully 
excised the head and neck of the femur for deformity following coxalgia in 
a boy who had suffered several years from that disease. In 1828, Mr. Hewson, 
of Dublin, made the next formal excision for caries of the head and neck of 
the femur; and his operation was followed by those of Textor in Germany, 
who resected the hip-joint four times for a similar state of the articulation. 
In England, Sir Benjamin Brodie, in 1836, excised the head of the femur for 
disease. The acceptance of the operation by British surgeons as an estab- EXCISION OF THE KNEE-JOINT. 
233 
lisbed surgical procedure was to be attributed in a large measure to the 
influence of Sir William Fergusson, who very early gave to the operation 
the weight of his great name and influence. 
Dr. Culbertson has tabulated 177 cases of complete excision of the hip- 
joint for disease. Of these, 90 recovered, 77 died, and in 10 the terminations 
were unknown. The mortality from these operations was, therefore, at least 
44 per cent. 
In 121 cases of hip-joint excision for gunshot wounds collected by this 
author, 106 (or 88.4 per cent.) died, 13 recovered, and 2 results were doubtful. 
In France, where the Moreaus had labored so hard to popularize resection, 
but little attention was given to the subject. Both Roux and Gerdy advo- 
cated the operation under certain limitations,-the former having, in 1847, 
divided the upper end of the bone for anchylosis. But Boyer, whose authority 
was wellnigh despotic, was adverse to the procedure. 
In 1849 the first operation of coxo-femoral excision for disease in the 
United States was executed by Dr. Wilcox, of Easton, Pennsylvania. This 
was succeeded, in 1850, by that of Professor Buchanan, of Glasgow, Scotland. 
Two years after, Professor Bigelow, of Boston, performed a similar operation 
upon a lad for caries. Excision has been brought to the favorable notice of 
the American profession largely through the labors of Professor Sayre, who, 
in 1844, executed successfully the removal of the upper extremity of the 
femur in a case of coxalgia. Since that period he has repeated the operation 
59 times. Similar excisions were also done by Markoe, Church, Mott, Krako- 
wizer, Holston, and Kinloch,-the number nearly every year increasing, so 
that in 1861 Hodges's collection embraced 44 operations of this nature. In 
Philadelphia, this operation has been practiced by almost every surgeon 
of prominence, and particularly by Dr. John Ashhurst and Dr. H. Lenox 
Hodge. 
The first excision of the head of the femur for gunshot injury, and chrono- 
logically the third, was done by Oppenheim, of Hamburg, Germany, on a 
soldier wounded in a Russo-Turkish battle. After undergoing the operation 
the patient was moved some distance to a hospital, and lived seventeen days, 
but died apparently from pyaemia or some blood-poisoning, contracted, it was 
supposed, from a patient who died in the same ward of the plague. In 1832 
Seutin excised, unsuccessfully, the head, neck, and some inches of the shaft 
of the femur of a private shot at the siege of Antwerp. Dr. Gross, in 1850, 
removed the head and neck of the thigh-bone for caries following gunshot 
injury. The patient died. A post-mortem examination revealed extensive 
disease of the kidneys and liver, which, together with two attacks of hemor- 
rhage, was chiefly concerned in occasioning a fatal termination of the case. 
The next operation was in 1854, by Prof. Baum, also with a fatal result. The 
year 1855 was remarkable for the performance of six excisions of the hip- 
joint,-all done during the Crimean War. The first of these was by Dr. 
Macleod, of Glasgow, who removed the head, neck, and great trochanter of 
the femur from a young man shot in an attack on a Russian fortress. This 
excision was followed by those of Mr. Blenkins, Staff-Surgeon Crerar, Mr. 
O'Leary, George Hyde, and Dr. Coombe. All of these patients died except 
Mr. O'Leary's, who recovered with a useful limb. 
The first American operation of the kind was performed by Dr. Sterling, 
of Cleveland, Ohio, in 1864, with an excellent recovery. 
Excision of the Knee-Joint.-With the exception of the elbow-joint, the 
knee-joint has been more frequently excised than any other articulation of 
the The operation is one of great severity as well as danger, and 
should not be undertaken except under a conspiration of the most favoring 
circumstances. The causes rendering a resort to the procedure necessary 
are strumous disease of the knee-joint, anchylosis, and gunshot and other 
injuries. 
The circumstances which make this excision so grave are, first, the mag- 234 
EXCISION OF SPECIAL JOINTS AND BONES. 
nitude of the joint, and necessarily the exposure of a large surface of cancel- 
lated tissue,-a condition favoring the introduction of septic matter into the 
blood; and, secondly, the peculiar form of the resulting wound, which is 
large and sacculated, and unfavorable to free drainage. 
Operation.-Park was favorable to a crucial incision for the exposure of 
the joint, the arms of the cross intersecting at the upper margin of the 
patella, while Moreau preferred an H-shaped incision. The easiest and most 
expeditious plan, however, of reaching the articulation-one which not only 
furnishes ample space for attacking the bones, but also admits of an accurate 
adjustment of the sides of the wound-is a semilunar or horse-shoe-shaped 
incision, first practiced by Mackenzie. 
The patient being etherized and brought to the end of the table, or to the 
edge of the bed, with the sound limb resting on a chair or stool, an assist- 
ant supports the leg of the affected side in an extended position. The sur- 
geon now makes a semilunar incision, with its convexity downward, across 
the limb, commencing behind the tuberosity of the condyle of the femur on 
one side, passing down the leg to a point opposite to the tubercle of the 
tibia, then across the latter prominence to the opposite side of the leg, termi- 
nating behind the tuberosity of the other condyle of 
the femur. The extremities of the incision being well 
back towards the ham will favor the drainage of the 
wound. 
In making the cut on the inner side of the joint, care 
must be taken not to wound the internal saphena vein, 
the position of which, if not visible, can easily be made 
so by applying pressure over the vessel just above the 
knee with the fingers, when the vein will become suffi- 
ciently distended to be recognized. 
The flap should next be raised, cutting off the tendo 
patellae as the dissection is carried upward, and thereby 
uncovering the front of the joint. (Fig. 1095.) 
The leg must now be flexed, while the lateral and 
crucial ligaments are being divided. Tn severing the 
latter, some caution must be exercised that the point 
of the knife does not get out of sight of the operator 
and puncture the tissues on the posterior aspect of 
the articulation; should this occur, the popliteal ves- 
sels would probably be damaged. 
At this stage of the operation the patella can be 
most conveniently removed. For this purpose the 
knife can be passed between the bone and its capsule. 
The division, next, of whatever soft parts may be 
in contact with the femur and the tibia will admit of the bones being pro- 
truded through the external wound. Their articular extremities can then be 
removed by Butcher's saw. The saw should be passed first beneath the 
femur and then beneath the tibia (if both are involved in the injury or dis- 
ease), and the cutting done from behind forward ; or, if this instrument is not 
at hand, interposing a wooden spatula behind the bones, they may be sawed 
off with an ordinary amputating saw from before backward. (Fig. 1096.) 
In the ablation of the bones there are two points which demand attention, 
-first, the direction of the section, and, second, the amount to be removed. 
With regard to the former, the obliquity of the condyles of the femur must 
be noted, and the incision made in a line exactly parallel with the articular 
surfaces of both condyles. If this direction is disregarded, and the section 
made directly transverse to the longitudinal axis of the bone, when the 
parts are adjusted the knee will have an outward curve. In cutting off the 
end of the tibia, the division should be made so as to leave a surface slightly 
oblique from before backward. 
The amount of bone which it is proper to remove, when the excision is 
Fig. 1095. 
Anterior semilunar flap cut 
and turned up in front of the 
thigh. EXCISION OF THE KNEE-JOINT. 
235 
executed on account of injury, must of course be limited only by the extent 
of osseous involvement. But when the case is one of disease, and in a young 
subject, before the consolidation of the epiphysis and the diaphysis has been 
completed, the morbid changes of the 
bones will generally be confined to the 
epiphysis alone, and the section, there- 
fore, should be made below the carti- 
laginous conjunction of this process 
with the diaphysis. The necessity for 
observing this rule is, that the opera- 
tion shall not interfere with the sub- 
sequent growth in the length of the 
limb. Accordingly, in dividing the 
femur, the saw must not be allowed 
to go above its trochlear surface. In 
dealing with the tibia the same course 
is to be pursued,-removing its ex- 
tremity as in cutting away the end 
of the femur. The saw should not 
trench, if it is possible to prevent it, 
on the cartilaginous conjunction of 
the epiphysis, though the latter plays 
a less important part in the subse- 
quent growth of the limb than does 
the ossifying centre at the lower end of the femur. (Fig. 1097.) 
When, after the removal of the diseased ends of the bones, it is found im- 
possible to straighten the limb because of the contracted state of the ham- 
string tendons, it will be better to perform tenotomy 
than unnecessarily to sacrifice the bone by making 
further sections. 
When it becomes necessary to carry the incision 
above the epiphysis, thereby arresting the growth 
of the limb in length, it has been suggested to re- 
move the epiphysis of the opposite limb in order 
to make them match. But such an operation will 
not receive the sanction of a conscientious surgeon. 
There is some difference of opinion as to the treat- 
ment of the patella in knee-joint excisions. The 
weight of surgical authority is-very properly, in my 
opinion-in favor of its removal, thereby diminishing 
very materially both the risks to life and the prob- 
abilities of a subsequent amputation. It can cer- 
tainly serve no good purpose by remaining, and in 
disease of the articulation it is liable to suffer in 
common with the other components of the joint. 
When the operation is performed for injury, and 
when this bone is not implicated, the necessity for 
its removal is not so urgent. 
Dressing.-After ligating such branches of the 
articular or other arteries as may require a thread, 
and thoroughly cleansing the wound with carbolated 
water, the bones should be accurately opposed, the one against the other, and 
the flap brought down and stitched, by means of a silvei* thread, to the part 
from which it was cut. Should there be difficulty in maintaining the ends 
of the bones fixedly in contact, they may be drilled and sutured together by 
strong wire. 
The proper immobilization of the limb after an operation of this nature is 
of paramount importance. 
The dressing which I prefer is one of plaster; and this must be applied, 
Fig. 1096. 
Joint opened and bones turned out ready to be excised- 
Fig. 1097. 
Section of the lower end of the 
femur and the upper end of the 
tibia, so as not to encroach on the 
cartilaginous union of the epiphy- 
ses with the diaphyses. 236 
EXCISION OF SPECIAL JOINTS AND BONES. 
as all others should, while the patient is under the anaesthetic. A piece of 
lint moistened with carbolic acid and sweet oil is first placed over the knee. 
The limb, while evenly supported in the extended position, is then to be 
covered with a roller from the foot to the groin, after which a sufficient num- 
ber of plaster bandages must be applied to form a stiff splint. As soon as 
these wrappers become stiff, they should be slit up over the front of the limb, 
so as to provide for any subsequent swelling which may occur. On each 
side, also, above and below the knee, the splint must be cut down so as to 
form sides which may be raised or lowered at pleasure and by means of 
which the wound can be dressed without disturbing the limb. (Fig. 1098.) 
Fig. 1098. 
Limb suspended in a plaster splint, its sides let down preparatory to changing dressing. 
A small opening will also be required posteriorly for the accommodation of 
the drainage-tube. If, now, strips of strong muslin be passed beneath the 
splint, and the limb be suspended, we have an appliance which secures to the 
parts the most perfect quiet possible. Under the most favorable circum- 
stances recovery will be tardy, requiring for its completion from eight to nine 
months. 
Professor Ashhurst prefers a bracketed wire splint (Fig. 1099), by which 
Fig. 1099. 
Ashhurst's wire splint. 
great convenience is afforded for the inspection and dressing of the wound. 
Other splints are used, such as Butcher's box, and the apparatus of Price 
(Fig. 1100), which resemble the bracketed splint employed by Ashhurst and 
Packard. Watson, of Edinburgh, applies a splint to the back of the limb, 
and, by means of a rod in front, suspends the extremity, somewhat after the 
plan of Nathan R. Smith. 
The average duration of the treatment varies in different cases. In 88 of 
the cases tabulated by Hodges it was about eight months, and was influenced EXCISION OF THE KNEE-JOINT. 
237 
very much by the presence or absence of the patella, being, in 48 cases in 
which that bone was removed, 225 days, and in 38 cases in which it was 
Fig. 1100. 
Price's bracketed splint. 
allowed to remain, 255 days. There are, however, many exceptions to this 
prolonged progress of cure,-instances, indeed, in which quite firm consolida- 
tion has taken place in two months. 
In order to determine the position which excision of the knee-joint should 
occupy as a resort of conservative surgery, it will be necessary to make a 
careful analysis of such data as may be at our command, by comparing 
excision with amputation. 
Hodges's tables contain 208 cases of excision of this articulation, 178 of 
which were performed for disease. Of this latter number, 102 (about 57 per 
cent.) proved unsuccessful,-the patients either dying or being compelled, 
afterwards, to submit to amputation. Of the remaining 106, there were 65 
which resulted in useful limbs, 14 operations proved either partly or entirely 
useless, and 27 had unknown or doubtful result. 
Of 19 cases of knee-joint excision at St. Thomas's and St. George's Hospi- 
tals, London, reported by Mr. Holmes, a useful limb was reported in 10 cases; 
of which 9 were children,-the subjects most proper for the operation. About 
52 per cent, of these excisions, therefore, were favorable to the operation. 
Dr. Wolff, of Berlin, gives a case of successful resection of the knee for 
articular caries in a child, attended with reproduction of bone.* 
Mr. Swain, the author of a " Prize Essay" on excisions of the knee-joint, 
tabulated 472 cases, with 356 recoveries. Among the recoveries are counted 
54 which subsequently underwent amputation, 41 of whom got well and 13 
died. The total number of deaths was 116, or a mortality of 24.57 per cent. 
The accuracy of these tables has been challenged by both Holmes and Bryant, 
and most justly so. No one for a moment, in the light of more recent sta- 
tistics, can believe that 302 useful limbs were obtained in 356 recoveries. 
There is no evidence that many of the cases placed to the credit of the latter 
were kept under observation for any extended length of time with a view to 
ascertain whether all the sinuses healed and permanent consolidation fol- 
lowed. And, besides, as Mr. Bryant has pointed out, among the recoveries 
after excision are enumerated 51 cases of secondary amputation, in which are 
included both fatal and non-fatal terminations. Again, when the mortality 
in these tables is studied in a particular class of patients (e.</., those in ado- 
lescent life), it is found to amount to 27.8 per cent.,-there being 27 deaths in 
97 cases of excision,-whereas in the thigh amputation for chronic disease in 
young persons of a like age, out of 69 cases 3 only proved fatal, or 4.3 per 
cent., according to Bryant's collection. If we extend the comparison between 
the two operations done for chronic joint disease to the class of patients 
between twenty-one and forty years of age, the same writer found that in 
excision the fatality amounted to 52.7 per cent., or 1 in 2,-39 dying out of 
74 cases; while in amputation the death-rate amounted to only 32 per cent., 
-38 dying out of 119 cases. 
In 1869, Penieres tabulated 431 cases of knee-joint excision, 300 of which 
recovered, or a death-rate of 30 per cent. Of this number, 247 got well 
* Archiv fur Klin. Chirurgie, Bd. 20, p. 771, Berlin, 1877. 238 
EXCISION OF SPECIAL JOINTS AND BONES. 
without any additional operation, 47 by secondary amputation, and 6 by a 
second excision. The results in these 247 cases were as follows: in 166 the 
result was good, and in 27 bad. If now we compare the results furnished 
by this table (which is exceptionally good) with the results in exactly the 
same number of amputations embraced in the collection of MacCormac and 
Bryant, it will be seen that the advantage, though small, is still in favor of 
amputation,-there being 335 recoveries in 431 amputations, or a death-rate 
of 22 per cent. 
Culbertson, in his " Prize Essay" in the American Medical Association 
Transactions for 1877, tabulates 745 cases of excision of the knee-joint, with 
240 deaths, or a mortality of 32 per cent. An analysis of these cases gives 
the following result: 
Excision for Gunshot Wounds. 
Partial 
17 cases. 
12 died. 
7JK1 
per cent, mortality. 
Complete 
44 " 
33 " 
75 
X u a 
Total 
61 " 
45 " 
75 
a a 
The death-rate following amputation at the lower third of the thigh, in 
military practice, according to Macleod, is 50 per cent. Legouest estimates 
it at 55 per cent. For amputation of the thigh in general, it amounted, in 
the late American war, to 73.23 per cent. The evidence, therefore, in this 
comparison is against excision. 
Partial 
12 cases. 
4 deaths. 
33 per cent. 
mortality. 
Complete 
16 " 
7 " 
45 " 
Total 
28 " 
11 " 
39 " 
(( 
Excision for Injury other than Gunshot. 
The injuries for which the excision was done were compound luxations, 
compound fractures of the patella, with lacerated wounds, and compound 
fractures of the condyles of the femur, with extensive disorganization of the 
joint. 
Norris gives 40 amputations of the thigh in the Pennsylvania Hospital, 
performed on account of injury, with 26 recoveries and 14 deaths, or a death- 
rate of 35 per cent. This does not materially differ from the mortality at- 
tending such operations in other hospitals, which will be found to range from 
35 to 57 per cent. The result here is favorable to excision in injuries of the 
nature just stated: 
Excision for Disease.. 
Partial 
18 cases. 
4 deaths. 
22 per cent, mortality. 
30 " " 
Complete 
585 " 
(( 
174 " 
Total 
603 " 
178 " 
31 " " 
[Of these 603 excisions, 78 were afterwards subjected to amputation, with 
65 recoveries, 12 deaths, and 1 undetermined result; which, with 6 undeter- 
mined excisions, would make the death-rate really 31 per cent.] 
The combined collections of amputations of the thigh for disease, tabulated 
by Bryant and MacCormac, number 431 cases, 335 recoveries, and 96 deaths, 
-a mortality of 22 per cent. This result is unfavorable to excision. 
In Hodges's tables are 178 cases of excision executed for disease. Of this 
number, 108 recovered and 70 died,-a death-rate of 39 per cent., or 17 per 
cent, in favor of amputation over excision. 
Excision for Deformity. 
Partial 
14 cases. 
2 deaths. 
14 per cent, mortality. 
Complete 
39 " 
5 " 
13 " " 
Total 
53 " 
7 " 
13 " " EXCISION OF THE KNEE-JOINT. 
239 
In this class, it will be noticed, the greatest success for excision was 
obtained. 
In the calculations of the percentage, all the cases in which the extent of 
the operation was not recorded were disregarded. 
The influence of age in determining the results of excision of the knee-joint, 
in cases operated upon fbr disease and injury, has been carefully analyzed by 
Culbertson. The data show that the fatality is greatest in the very young 
and the aged. Thus, in 19 cases, in which the subjects were from one to five 
years of age, the mortality was 38.9 per cent.; in 106, between five and ten 
years, it was 16.2 per cent.; and in 99 cases, between ten and fifteen 
years, it was 17.2 per cent. From the last period of life upward there was 
a very rapid increase in the death-rate, which amounted, in patients over 
forty, to 52.6 per cent. 
Mr. Willett, in the St. Bartholomew tables, gives 38 cases of knee-joint 
excision, with 8 deaths, or 21.05 per cent, of mortality; and Mr. Sydney 
Jones gives 10 cases, with 3 deaths, or a death-rate of 30 per cent. To these 
cases we may add 27, reported in 1873,* 5 of which ended fatally, with 
1 secondary amputation, or 20 per cent, of failure; and 40 cases given by Sir 
W. Fergusson, done for osseous anchylosis, 30 of which recovered and 10 
died,-a death-rate of 25 per cent. 
According to the statistics compiled by Mr. Knoll,f out of 104 knee-joint 
excisions, performed exclusively by German surgeons, 52, or 50 per cent., 
died. Drs. Drake and FenwickJ have reported 5 cases of excision of the 
knee-joint for disease, with 4 recoveries and 1 death. The general rate 
of mortality for this excision, deduced from all the data furnished by the 
different writers quoted, may, therefore, be approximately set down at 32.4 
per cent. 
The great fatality of knee-joint excisions for shot injury in military as 
compared with civil practice will further appear by again referring to Spill- 
man's collection of cases. This writer gives 13 instances of this operation 
in civil practice, performed for gunshot wounds, with 3 deaths, or a death- 
rate of 39 per cent.; while in 21 similar injuries in military practice, 19 proved 
fatal, or a death-rate of 90 per cent. 
The testimony of Peniere is to the same effect. Of 7 cases of excision of 
the knee-joint, performed in civil practice, there were 3 deaths, or a death- 
rate of 42 per cent.; while of 20 cases in military practice, 17 died, or a death- 
rate of 85 per cent. 
Of the 11 cases of this excision performed during the War of the Be- 
bellion, 9 died,-a mortality of nearly 90 per cent. 
Dr. 8. W. Gross has tabulated 35 cases of the knee-joint excision for gun- 
shot injury, 11 of which recovered and 24 died,-a death-rate of 68.57 per 
cent. The complete excisions proved more fatal than those which were par- 
tial by 33 per cent. And the primary were more successful than the secondary 
operations, the difference being 10 per cent, in favor of the primary. 
Deductions.-The deductions which may be legitimately drawn from the 
analysis of the foregoing collections of knee joint excisions may be for- 
mulated as follows: 
(1) That, in military practice, this operation should be abandoned, and 
amputation should be substituted for it. 
(2) That there remains a large class of cases, consisting of compound lux- 
ations, lacerated wounds of the joint, and of chronic disease, which occupies 
debatable ground, the treatment of which, by excision or by amputation, can 
only be decided on a careful consideration of the individual cases. 
Among these considerations may be mentioned the extent of the damage 
inflicted on the soft parts and the bones; the integrity of the principal blood- 
vessels and nerves; the age and habits of the patient; the ability to com- 
* New Sydenham Society's Biennial Report for 1873-74, p. 281. 
f Dissert. Inaug., Leipsic, 1866. 
j Canada Medical and Surgical Journal, 1878, vol. vi. pp. 261-269. 240 
EXCISION OF SPECIAL JOINTS AND BONES. 
mand prolonged care and skillful treatment; and, finally, the condition of the 
internal organs. 
The most favorable cases for excision are, undoubtedly, young subjects, 
between the ages of ten and twenty, suffering from chronic disease of the 
articulation limited to the epiphysis, free from organic disease, and not worn 
down by suppuration and constitutional irritation. When such a combination 
of favoring circumstances presents itself, excision should always be adopted. 
If not, it will be better to abandon all ideas of the operation and substitute 
for it amputation. 
Again, in patients under five or over thirty years of age, the mortality 
attending excision is so great that amputation is to be preferred. 
The success attending excision for deformity has been so uniformly favorable 
that cases of this class, when not correctible by subcutaneous osteotomy, 
may with propriety be regarded as appropriate subjects for the operation. 
Even when the excision in these cases fails, the failure, it has been shown, 
does not materially diminish the probability of successful amputation. 
Skill in the execution of an excision, and a judicious selection of cases and 
of the after-treatment, conspire to lessen materially the mortality. Of 39 
cases of this operation practiced by Professor Humphry, of Cambridge, 
England, for disease, 28 recovered with sound and useful limbs, 2 died from 
causes which did not appear to be directly traceable to the operation, and 
9 required amputation, of whom 4 died. Mr. Jones, of Jersey, England, re- 
sected the knee articulation 15 times, with a single death; and Mr. Gant, 12 
times, for disease, with a single death. Of Mr. Gant's 12 cases, 3 were 
afterwards treated by amputation, and one of these after two excisions had 
failed. Thomas Smith, of London, made 14 excisions, with 2 deaths. These 
results are in remarkable contrast with those of 17 similar excisions done in 
France, in which there were 15 deaths and 2 recoveries. 
There is one very important matter connected with these excisions on 
which statistics are very defective; that is, the real, permanent value of the 
limb in those cases which are reported as cures. The phrase generally em- 
ployed to indicate the successful result is, "recovered with a useful limb,"- 
a very vague expression. The knowledge which we require as a basis for 
any just estimate of the merits of the operation must be of a more circum- 
stantial character,-as, for example, the degree of shortening; the nature 
of the union ; the position of the limb; its ability to tolerate pressure and 
motion; and whether its usefulness was permanent. These facts can be 
determined only after the lapse of two or more years succeeding the recovery. 
History.-Mr. Filkin, of Northwich, England, was the first surgeon to per- 
form a complete excision of the knee-joint (August 23, 1762). The patient 
recovered with a useful limb. Mr. Park, of Liverpool, who was the first to 
introduce this operation to the profession, executed the second total excision, 
and (in 1789) a third, which was done for disease. Three years later, Sep- 
tember 17,1792, the elder Moreau, of Bar-sur-Ornain, did a similar operation 
for caries, and another in 1802. These were the first of the kind done in 
France. In 1809, Mulder, of Groningen, Holland, resected a knee articula- 
tion ; and this was followed by the operation of the younger Moreau, in 1811, 
Roux's, in Paris, in 1816, and TextoFs, in 1821,-the last being probably the 
first done in Germany. 
In 1823 the operation was introduced into Ireland by Sir Philip Crampton, 
and in the same year into Scotland, by Syme. Twelve years later, Demme, 
of Berne, performed the first excision of this joint in Switzerland. In 1842 
it was repeated in Italy, by Lombardo, of Pavia. 
Following these are to be mentioned one by Wcdderburn, of New Orleans, 
Louisiana, in 1852, one by Quackenbos, in 1853, one by Adelmann, of Dorpat, 
Russia, in 1853, and one by Esmarch, of Kiel, Denmark, in 1858. 
The first excision for shot injury was in 1809, by D. J. Larrey, in Benevento, 
Spain. Similar operations were done in 1831, by Thedan, of Germany, and 
Percy, Laurent, and Champion, of France. EXCISION OF THE ANKLE-JOINT. 
241 
The first total resection for shot wounds w'as performed by J. II. Lakin, 
of England, October 5, 1855, at Sevastopol. In the United States, the first 
partial excision for gunshot injury was made by Hodgen, of St. Louis, in 
1862; and the first total operation by Surgeon A. A. Barrister, U.S.A., in 
September of the same year. These excisions are followed by the case of 
Boute, Troy, N.Y., October, 1862. 
In 1857, Cooper, of San Francisco, made the first complete excision in this 
country in civil practice. 
Excision of the Ankle-Joint. 
Excision of the ankle-joint has been performed for gunshot injury, for 
compound luxations, and for disease. The propriety of the operation may, 
however, be considered as still under discussion. 
Operation.-To prevent bleeding, the limb, after the patient is etherized, 
may be emptied of its blood by an Esmarch bandage. 
The operation which gives the freest access to the joint is that devised by 
Mr. Hancock. It consists in first placing the foot on its inner side, and then 
making an incision along the posterior face of the fibula, commencing three 
inches above its lower extremity, and, after reaching the end of the malleolus, 
changing its direction, and terminating about half an inch short of the 
metatarsal bone of the little toe. The flap is next raised and reflected for- 
ward, exposing the surface of the fibula. In doing this, care must be taken 
not to injure the tendons of the peroneus longus and brevis muscles, which 
lie against the posterior and outer face of the bone. The fibula must next 
be cut through with strong bone pliers, and its lower extremity dissected 
out. 
As the joint is now exposed on its outer aspect, it will be proper, before 
proceeding further, to examine the condition of the articulation. Should the 
disease be found to be very limited and accessible, this one incision may suffice 
for its removal; and it answers to the plan directed by Dr. Buchanan, of 
Glasgow. When, however, this is not the case, it will be necessary to place 
the foot on its outer surface, and to make a second incision, in form and ex- 
tent like the first, along the inner angle of the tibia, and terminating at the 
internal cuneiform bone. (Fig. 1101.) The flap is to be dissected back, ob- 
serving to keep close to the bone, in order that the tendons of the tibialis 
Fig. 1101. 
Inner and outer lines of incision. 
posticus and flexoi' longus digitorum muscles, together with the posterior 
tibial artery, veins, and nerves, may be raised without injury. These parts 
being held aside, the internal malleolus may be cut away by the bone pliers, 
or the internal lateral ligament may be first divided, by shaving round the 
end of the malleolus. 
Clearing the bone now, in front and behind, with the handle of the scalpel, 
VOL. II.-16 242 
EXCISION OF SPECIAL JOINTS AND BONES. 
or the finger, and strongly everting the foot, the tibia and the upper surface 
of the astragalus will be exposed at the internal wound. A narrow-bladed 
saw must now be entered through the internal wound, passed behind the 
tibia, and made to appear at the external opening, when the bone can be 
divided from behind forward. This done, the upper surface of the astrag- 
alus may be sawn off. If the disease has penetrated deeply into the sub- 
stance of the latter bone, its entire excision will be indicated. 
Dressing.-One or two small arterial branches will probably require the 
ligature. After this is done, the wound must be thoroughly washed out with 
carbolated water; a drainage-tube passed through from one side to the other 
of the joint; the sides of the incision closed by the interrupted suture; and 
a piece of lint, moistened with sweet oil and carbolic acid, laid over the 
parts. 
The foot and limb being next covered with a bandage, plaster rollers should 
be applied, the recurrents extending from the metatarso-phalangeal joints to 
the knee. While this is being done, care must be taken that the foot shall 
have the proper angle with the leg,-that which conforms to its position in 
health ; and for this purpose the foot must be held by the hand of an assistant 
until the plaster has hardened. 
Traps are next cut on the inside and outside of the splint opposite the 
wounds. Or, the splint may be slit down on each side, so as to form two 
sides, which can be lowered or elevated at pleasure, and thus admit of the 
interposition of oakum, an article well adapted to absorb the discharges 
issuing from the wounds. 
On the third day following the operation the sides of the plaster splint 
should be let down and the parts carefully examined. If there is no dis- 
charge from the wounds and no unusual swelling, it will not be necessary 
to renew the dressing. When suppuration occurs, the accumulation can 
readily be washed out by fitting the nozzle of a syringe to the drainage-tube 
and injecting into the cavity of the wound a stream of tepid carbolated water 
or a solution of the permanganate of potash. 
After thoroughly cleansing the parts, a strip of lint saturated with carbo- 
lated oil must be laid over each wound ; a little oakum must be packed around 
the joint; and the sides of the splint replaced and retained by a strip of bandage. 
If the limb is now suspended, as in excisions of the knee-joint, the appa- 
ratus will be complete. 
In the absence of the materials for the plaster dressing, the foot and the 
leg should be placed in a fracture-box, and surrounded with bran ; and to 
secure greater quiet, the box should be suspended, as in Fig. 831, vol. i. page 
985. 
After the appearance of suppuration, the dressing will require to be re- 
newed daily. If the antiseptic or 
Lister plan is adopted, there will be 
less necessity for disturbing the dress- 
ing so frequently. 
The constitutional treatment must be 
guided by the necessities of the case. 
Anodynes may be administered freely 
if there is much pain. In order to 
provide against the exhaustion of the 
system, an ample supply of nutritious 
food, together with tonics and stimu- 
lants, will be necessary. 
The length of time requisite to ac- 
complish a cure, provided the case 
does well, will vary from three to five 
months. Very little deformity can 
be noticed in the appearance of the foot. (Fig. 1102.) 
The Subperiosteal Method, as prescribed by Ollier and Langenbeck, 
Fig. 1102. 
Appearance of the foot after excision of the ankle- 
joint. EXCISION OF THE ANKLE-JOINT. 
243 
differs from the plan already described only in preserving the periosteum, by 
peeling this membrane from the bones excised, by means of the periosteal 
elevator. If the surgeon is successful in effecting this detachment in a 
reasonably perfect manner, a considerable reproduction of new bone may be 
anticipated, to take the place of that removed. This will not only diminish 
the shortening consequent upon-the operation, but it will also insure a more 
useful limb. 
Results of Ankle-Joint Excisions.-Tn order to determine the true 
value of ankle-joint excision, it should be compared in its results with those 
of expectancy and amputation. The profession is certainly not yet in pos- 
session of a sufficient number of facts to settle the question of the relative 
merits of these methods. If it is decided by the precarious data which are 
at present within reach of the profession, the class of cases which will justify 
a resort to excision of this joint is very limited indeed, and I believe this 
will be the final verdict after the observations shall have accumulated suffi- 
ciently to warrant an authoritative decision of the points at issue. 
Mr. Stokes has recorded 51 cases of excision of the ankle-joint for disease, 
38 of which were reported successful, or about 74 per cent. In 68 cases of 
this excision, performed for compound fracture and for dislocation, as tabu- 
lated by the same writer, 11 died, or nearly 1 in 6; and 4 were subjected to 
subsequent amputation; so that the operation was a failure in more than 22 
per cent, of these cases. 
Mr. Hancock reports 32 cases of excision of the ankle-joint for disease. 
The ages of the patients varied from four to forty-two years. The sexes 
show the proportion of 16 males to 6 females. Of the 32 patients operated 
upon, 21 recovered with good and useful limbs; 7 died; 2 underwent secondary 
amputation, and recovered; and in 2 the result was undecided. The pro- 
portion of deaths, consequently, exceeds 21 per cent.; the proportion of 
known failure is nearly 30 per cent.; and the proportion of favorable results, 
so far as ascertained, is 65 per cent. It is stated, however, that 4 of the 
patients who died were suffering with consumption of the lungs, and 1 with 
syphilitic disease. 
Professor Spillman, of France, has published the results of 72 resections 
of the tibio-tarsal articulation, performed for disease or pathological causes.* 
Of this number, 43 were reported as successful, and 7 as partially successful; 
14 patients died; in 5 cases the termination was not given; and 3 underwent 
subsequent amputations. Of those who died, it is stated, 3 were suffering 
from disease other than that of the joint. According to these data, the pro- 
portion of failures of the operation is over 23.5 per cent.; the death-rate at 
least 19.4 per cent.; and the proportion of complete success is not known to 
have exceeded 60 per cent. 
This French author states that 12 of the above-mentioned cases of joint 
disease had a traumatic origin, and in 11 of these the operation was successful. 
In 37 of these resections, which were strictly pathological cases, in which 
the tibia was involved, there were 22 cures; 1 case in which the disease lin- 
gered two years after the operation; 7 deaths; and 7 cases in which subse- 
quent amputation was done, with a fatal result in 2, and a good result in 2; 
while of the 3 others no note is given,-in fine, 9 deaths, or a death-rate of 
24.3 per cent., and 15 unsuccessful operations out of 37, or 40 per cent, of 
failure. 
Of 68 resections, performed for luxations and compound fractures of the 
tibio-tarsal joint, as enumerated by Spillman in the same publication, 44 
were decidedly successful; 6 partly successful; 13 were fatal; 3 doubtful; 
and 2 underwent amputation. The mortality in this class of cases, ac- 
cording to these statistics, appears to be about 20 per cent.; the proportion 
of failure in the operation, over 22 per cent.; and that of decided success, 
64.7 per cent. 
Heyfelder, in 1867, had reported 26 examples of this excision of the ankle 
* Archives Generales de MSdecine, vol. xiii., 1869, p. 155. 244 
EXCISION OF SPECIAL JOINTS AND BONES. 
joint, of which number 5 died, or about 19 per cent.,*-a mortality corre- 
sponding with that deducible from the data of Spillman. Jaeger also reported 
24 cases of this excision, 23 of which, it was claimed, had been successful, 
and 1 had died from the operation. These cases are not taken into account 
in the final estimate. 
In 1873, Heyfelder reported 174 cases of resection (both partial and com- 
plete) of the ankle-joint. Of this total number, 151 recovered with a useful 
limb, and 7 with a useless limb, and 16 of the patients died.f The proportion 
of failure in these excisions, including those which were partial operations, 
was, therefore, 13.2 per cent. 
Dr. L. Lauff, in a careful dissertation " On the Statistics of Excision of the 
Ankle-Joint," published at Halle, 1872, records 104 cases (though not all re- 
cently performed). Of these, 33 excisions were performed for caries of the 
ankle-joint, of which only 17 were thoroughly cured (or 51.5 per cent.), and 
10 died,-a death-rate of 30 per cent. 
Culbertson has tabulated 147 cases of partial, and 7 cases of complete, ex- 
cision of the ankle-joint, performed for injuries other than gunshot, with 19 
deaths, or a mortality of 12.5 per cent. 
The same writer has also collected 124 cases of similar excisions executed 
for disease, of which 68 were partial, 51 complete, and 5 uncertain, with 10 
deaths, or a mortality of 8.05 per cent. It appears, however, that 12 per 
cent, of those done for disease subsequently demanded amputation, making 
the proportion of failures over 20 per cent.,-a circumstance which materially 
tells against the excision. The proportion of useful limbs after recovery is 
estimated by Culbertson at 66 per cent. The proportion of failure, therefore, 
was 34 per cent. 
Between 1850 and 1872, Langenbeck performed 4 subperiosteal excisions 
of the ankle joint and os calcis, with the result of very complete reproduc- 
tion of bone, and in 2 cases the joint recovered excellent motion. 
Mr. Holmes, in 1878, reported 7 cases of ankle-joint excision for disease, of 
which number 1 proved fatal, and 1 called for subsequent amputation.| 'This 
writer attaches no importance to the preservation of the periosteum. He 
also strongly advocates the removal of the astragalus entire, a practice which 
certainly renders a reproduction of the disease less probable. 
Dr. Bergmann, of Dorpat, has collected 11 cases of excision of the ankle, 
with 2 deaths,-a death-rate of 18.18 per cent. 
Comparison ivith amputation.-There are three amputations with which ex- 
cision of the ankle-joint may appropriately be compared,-viz., amputation 
of the leg, Syme's amputation, and that of Pirogoff. 
1. The average mortality attending amputation of the leg for pathological 
disease varies from 20 to 25 per cent. If we compare this proportion with 
the death-rate from excision, as deduced from the most exact data already 
given from different sources, and which varies from 8.05 per cent. (Culbert- 
son) to 19.4 per cent. (Spillman), the weight of evidence is against amputa- 
tion, and in favor of excision, for disease of the ankle-joint. 
2. Amputation of the ankle-joint, commonly known as Syme's amputation, 
according to the statistics of Mr. Hancock, who has analyzed 219 such cases, 
144 of which were undertaken for disease, with 10 deaths, is attended with 
a mortality of about 1 in 14 cases, or 6.9 per cent.,-a result which is favor- 
able to amputation. 
3. According to the statistics of Butcher, who has examined into the history 
of 58 cases of Pirogoff's operation (in which 5 proved fatal), the rate of 
mortality is a fraction over 9 per cent. This result, likewise, is in favor of 
amputation, and against excision. 
For further statistics of the results of amputations, the reader is referred 
to data hereafter to be given. 
* The Lancet, 1867, vol. ii. pp. 121, 122. 
f Klinische Vortrage, 1873, cit. London Medical Record, July 16,1873. 
+ Medical Examiner, March 7, 1878, p. 198, and London Medical Record, May 15, 1878. EXCISION OF THE ANKLE-JOINT. 
245 
But, when instituting such comparisons, there is clanger of grave error, 
unless it be borne in mind that while in amputations the resultant deaths 
reported generally cover all the cases of surgical failure, it is otherwise in ex- 
cisions. The proportion of failures in the excisions reported largely exceeds 
that of deaths. And this excess appears to be especially noteworthy in the 
excisions performed for causes strictly pathological,-the very class of cases 
the results of which we are most concerned to ascertain. Thus, for example, 
in all the excisions done for causes strictly pathological, given by Dr. Spill- 
man, although the death-rate was not reported at more than 24.3 per cent., 
the failure-rate amounted to no less than 40 per cent. And in the tabulated 
excisions of every kind given above, where the data are comparable, the fail- 
ures, as stated, averaged not less than 20 per cent., and the successes claimed 
do not exceed 70 per cent. Indeed, a safe and crucial analysis of all the fig- 
ures would justly require us, when the highest proportion of success claimed 
in all the comparable excisions is only 70 per cent., to set down the general 
proportion of failures at 30 per cent. These facts are very pertinent in any 
fair inquiry into the comparative merits of excision and amputation. For, 
as M. Polaillon, when discussing the statistics of resections of the os calcis, 
has forcibly urged,* "it is clear that the end of the excision is not only the 
conservation of the foot, but, moreover, the conserving of a foot useful for 
standing and walking. If this end is not attained, the result ought to 
bo charged as bad." That these statistics of excisions also give a distorted 
representation of their comparative value is further evidenced by the fact 
that the statistics of amputations arc immensely more numerous and more 
accurately reported than those of excisions. The excisions, moreover, have 
generally been executed in selected cases, by the masters of surgery, and 
followed up usually by the best treatment, while the amputations have often 
been done by men of inferior skill, with inferior appliances for securing a 
successful result. 
History.-Excision of the ankle-joint is a very old operation. As early 
as 1670, Fabricius Ilildanus cut out the entire astragalus in a case of com- 
pound luxation. In 1716, Gouey, of France, removed, on account of necrosis, 
first the lower end of the fibula, and at a second operation the astragalus. 
The astragalus was again, in 1741, excised by Yonder Broilie, in a case of a 
luxation attended with an external wound. During the succeeding seventeen 
years four similar operations were executed, the surgeons being Aubray, 
Ferraud, J. S. Desault, and Manduyt. In 1782, Cooper, of Bungay, England, 
removed the tarsal extremity of both bones of the leg for a compound luxa- 
tion of the foot. Hey, of Leeds, England, in 1776, performed a similar ex- 
cision for injury, and this was followed, in 1782, by the operations of Kirtland 
and the elder Moreau. The last-named surgeon, in 1788, removed, for disease, 
both the astragalus and the scaphoid bone. In 1786, Hey again resected the 
lower end of the tibia and fibula in a case of compound dislocation. Two 
years later, Taylor, of Wakefield, England, and Tyre, of Gloucester, each 
cut away the lower extremity of the tibia on account of injury. In 1792, 
quite a number of excisions of the astragalus were made by Chorley and 
Linn, of England, the two Moreaus and Laumonier in France, and Rumsey, 
of Amsterdam. In Prussia, the first operation of the kind was done by 
Mulder, of Groningen, in 1810. 
The first total excision of the ankle-joint appears to have been made in 
April, 1792, by the elder Moreau, and in Scotland by Liston, in 1818. 
In America, Morrogh, of Clifford, New Brunswick, performed the first 
complete excision in 1854. In 1859, Forster, of Portland, Maine, removed 
the end of the tibia and a portion of the astragalus; and the same year a 
total excision of the joint was done by Cabot, of Boston. As early, however, 
as 1835, partial excisions of this joint had been performed in this country 
by Welles, of South Carolina, Stevens, of New York, Gillespie, of Virginia, 
and Nathan R. Smith, of Baltimore. To these may be added one by Manson, 
* Archives Generales de Medecine, September, 1869, p. 2«9. 246 
EXCISION OF SPECIAL JOINTS AND BONES. 
of Missouri, in 1839; one by Hildreth, of Ohio, in 1844; one by Robertson, 
of Charleston, South Carolina, in 1851, and another by Gurdon Buck, of New 
York, the same year. 
The first excision for gunshot injury was executed by a surgeon named 
Reed, in 1819 : the patient recovered after undergoing secondary amputation. 
In 1855, during the Crimean War, Macleod, of Glasgow, removed the os calcis 
and a part of the astragalus for a similar injury. 
The first total excision for gunshot injury in the United States was per- 
formed in 1864, by Bontecou, of Troy, N.Y. 
Langenbeck has the credit of making the first subperiosteal excision. 
Excision of the Clavicle. 
Excision of the clavicle, in whole or in part, may he required on account 
of morbid growths, intractable luxations, gunshot and other injuries, and for 
the cure of caries or necrosis. 
Except when the bone is involved in a diseased growth, or when the 
associate parts are united by inflammatory changes, its extirpation is not a 
difficult task. 
Operation.-An incision should be made along the course of the bone, 
extending from its acromial to its sternal articulation. After dividing the 
superincumbent tissues, including the periosteum, the bone should be shelled 
out from its surrounding parts by an elevator rather than by a knife. 
Its acromial articulation is next to be severed, by dividing the capsular 
and coraco-clavicular ligaments. The bone should now be seized and pulled 
forcibly forward, and its remaining attachments divided from the acromial 
towards its sternal end; and on reaching the latter, the disjunction can 
be completed by dividing the capsular, interarticular, and costo-clavicular 
ligaments. The vessels should be tied as the operation progresses. 
Dressing.-After the removal of the bone, the sides of the wound must 
be brought together by the interrupted suture, and a water or a carbolized 
dressing applied. This can be best kept in place by a spica bandage of the 
shoulder. In addition, a pad should be placed in the axilla, and the arm 
supported by means of a Velpeau roller. 
In case of necrosis or of comminution, the extirpation of the clavicle is 
not an operation of any peculiar difficulty. But, when undertaken for en- 
cephaloid, sarcomatous, or other growths, the inflammatory alterations of 
the adjacent cervical tissues will render the extirpation a tedious, embarrass- 
ing, and bloody procedure. 
Usefulness of the arm.-The movements of the arm after recovery from 
the operation have not been seriously impaired; and in some instances the 
patients have experienced but little diminution of muscular power in the 
limb, being able to raise and carry heavy weights. In a case in which I 
removed the entire clavicle at the University Hospital, the bone was re- 
produced in its whole extent. 
History.-Complete excision of the clavicle was performed as early as 
1732, by Kemmer, on account of cancer. In this country the bone was first 
extirpated by McCreary, of Kentucky, in 1811 or in 1813. 
The following table, framed from the collection of cases by Otis, and from 
those recorded in various medical journals, embraces most, if not all, of the 
cases of complete excision of the clavicle which, so far as I know, have been 
reported: EXCISION OF THE CLA VICLE. 
247 
Complete Extirpations of the Clavicle. 
No. 
Operator. 
Date. 
Cause. 
| Recovery. 
Death. 
Reference. 
1 
McCreary. 
1811 or 
1813. 
Scrofulous ne- 
crosis. 
1 
New Orleans Medical and Surgical Journal, 1850, vol. vi. p. 
471. Smith's Principles and Practice of Surgery, vol. ii. 
p. 335. 
2 
Meyer. 
1823. 
Caries. 
1 
Encyclop, Wdrterbuch der Med. Wissenschaften, B. xxix. 
S. 96, and Graefe and Matthias Jour., 1833, B. xix. S. 71. 
3 
Mott. 
1828. 
Osteosarcoma, 
1 
American Journal of Medical Sciences, 1828, vol.iii. p. 100. 
4 
Wutzer. 
1825. 
Caries. 
Orsbach, De resectione Clavicul.e, Bonn, 1833, p. 6. 
5 
IV utzer. 
1832. 
Caries. 
Orsbach, De resectione Claviculee, Bonn, 1833, p. 6. 
6 
Warren, J. C. 
1832. 
Osteosarcoma. 
i 
American Journal of Medical Sciences, 1833, vol. xiii. p. 17. 
7 
8 
Roux. 
Mazzoni. 
1834. 
1835. 
Caries. 
1 
i 
Miguel, Bull. Gen. de Therap., 1834, t. vi. p. 246. 
Gazette Medicale de Paris, 1838, p. 460. 
Med.-Chirurg. Trans., 1838, vol. xxi. p. 135. 
9 
Travers. 
1836. 
Tumor follow- 
ing injury. 
1 
10 
Biangini. 
1838. 
Necrosis, 
1 
Gazette Medicale de Paris, 1838, p. 460. 
11 
Kunst. 
1838. 
Injury. 
1 
Deutsche Klinik, 1850, B. ii. S. 263. 
12 
Wedderburn 
1852. 
Caries. 
1 
New Orleans Monthly Medical Register, 1852, vol. ii. p. 1. 
13 
Bartlett. 
1853. 
Exostosis. 
1 
St. Louis Medical and Surgical Journal, 1854, vol. xii. p. 64. 
14 
Owens. 
1854. 
Osteosarcoma. 
1 
New Orleans Medical and Surgical Journal, 1854-55, vol. xi. 
p. 164. 
15 
Blackman. 
1856. 
Caries. 
1 
The Western Lancet, 1856, vol. xvii. p. 336. 
16 
Curtis. 
1857. 
Malignant dis- 
ease. 
1 
American Journal of Medical Sciences, 1857, vol. xxxiv. p. 
350. 
17 
NSlaton and 
Richaud. 
1857. 
Caries. 
1* 
Ollier, Trait® experim. et clin. de la Regener. des Os, Paris, 
1867, t. ii. p. 174, 
18 
Esmarch. 
1859. 
Osteosarcoma. 
i 
Nissen, Diss, de resectione, 1859, p. 7. 
19 
20 
Heyfelder. 
Gunn. 
1860. 
1860. 
Caries. 
1 
Deutsche Klinik, 1860, B. xii. S. 291. 
Chicago Medical Journal, 1868, vol. xxv. p. 301. 
Medical History of War of Rebellion, 1870, Part I. vol. ii. 
p. 557. 
21 
Confederate 
surgeon. 
1864. 
Shot injury. 
22 
Palmer. 
1864. 
Shot injury. 
1 
Medical History of War of Rebellion, and American Journal 
of Medical Sciences, 1865, vol. xlix. p. 367. 
23 
Bowe. 
1866. 
Caries. 
1 
Medical Times and Gazette, 1866, vol. ii. p. 194. 
24 
Irvine. 
1867. 
Necrosis. 
1 
Lancet, 1867, vol. i. p. 206. 
25 
Morin. 
1868. 
Malignant dis- 
ease. 
1 
Gazette Medicale de Lyon, 1868, No. 8, p. 93. 
26 
Dawson. 
1868. 
Necrosis. 
1 
Cincinnati Lancet and Observer, 1868, vol. xi. p. 1. 
27 
Cooley. 
1869. 
Osteosarcoma. 
1 
Leavenworth Medical Herald, 1869, vol. iii. p. 302. 
28 
Varick. 
1870. 
Tumor. 
1 
New York Medical Record, 1870, vol. iv. p. 510. 
29 
Eve. 
1870. 
Malignant dis- 
ease. 
1 
Nashville Journal of Medicine and Surgery, 1871, vol. i. p. 
68. 
30 
31 
32 
Britton. 
Langenbeck. 
Cooper. 
1870. 
1870. 
1870. 
Malignant dis- 
ease. 
Malignant dis- 
ease. 
Malignant dis- 
ease. 
1 
1 
1 
Medical Times and Gazette, 1870, vol. i. p. 551, 
33 
34 
Porquet. 
Carswell. 
1874. 
Caries. 
Necrosis. 
"1" 
22 
6 
L'Annfie Mgdicale, May, 1877. 
6 results undetermined. 
* Lived one year. 
There were of the whole numbex* 22 recoveries, 6 deaths, and 6 termina- 
tions unknown, which gives a mortality of about 17 per cent. 
As regards the causes for which these operations were performed, they 
were- 
Caries 
10 
Necrosis 
5 
Osteosarcoma 
5 
Malignant disease 
6 
Shot injury 
2 
Exostosis 
1 
Tumor 
2 
Injury 
1 
Unknown 
2 
Total 
34 
Of 31 cases of partial excision, practiced during the late American war for 
gunshot injury, uncomplicated by wound of the lung, 23 recovered, 6 died, 
and in 2 the result was undetermined. 248 
EXCISION OF SPECIAL JOINTS AND BONES. 
Of 4 cases complicated by lung injury, 3 died and 1 recovered. One case 
complicated by wound of subclavian artery died. One case for necrosis 
following simple fracture recovered. 
The following is a collection of 38 cases of partial excision of the clavicle: 
For necrosis 
.. 6 
cases. 
5 
recoveries. 
1 undetermined. 
" shot injury 
.. 13 
Ci 
11 
a 
2 died. 
" caries 
.. 5 
CC 
5 
a 
... 
(( disease 
.. 3 
Ci 
3 
cc 
" osteosarcoma 
.. 3 
a 
3 
a 
" compound luxation.... 
.. 1 
cc 
1 
" osteitis 
.. 1 
a 
1 
iC 
" cancer 
.. 1 
1 " 
Cause not stated 
.. 5 
iC 
5 
cc 
-- 
- 
• ■ - 
- 
Total 
.. 38 
cc 
34 
Ci 
3 " 
1 
Dr. Schneider, of Konigsberg, has reported* (1877) a case of subperiosteal 
section of a piece of the clavicle an inch and a half long, with five ribs, for 
gunshot injury with much laceration of the lung; and Dr. Varick, of Jersey 
City, has a second case of a similar operation (the patient recover- 
ing with a firmly ossified clavicle and excellent use of the arm), with a col- 
lection of seven other cases of subperiosteal resection of the clavicle, followed 
by partial or entire reproduction of the bone. 
Excision of the Scapula. 
Excision of the scapula may be rendered necessary by reason of caries, 
necrosis, morbid growths, shot wounds, and other forms of injury. The 
scapula may be removed alone, or in conjunction with the clavicle and the 
arm,-the latter being an extirpation of the entire upper extremity. 
Acromion Process.-When this part of the scapula demands removal for 
caries, the bone should be exposed by an incision extending from the clavicle 
back to where this process terminates in the spine, detaching, by means of 
the elevator, the periosteum along with the attachments of the deltoid and 
trapezius muscles. The clavicle should now be separated at the place of its 
articulation with the acromion ; or, if it participates in the disease, it may 
be divided by the saw at a point where its structure remains sound. The 
next step is to sever the coraco-acromial ligament, when the diseased bone 
can be cut away either by the saw or by the bone pliers. 
Total Excision.-The method of excising the scapula must necessarily 
be modified by the condition of the soft parts and the character of the disease 
or injury. Ordinarily, the bone will be best exposed by making two incisions, 
one extending from the acromion process outward as far as the upper angle, 
or the upper extremity of its vertebral border; and the other beginning at 
the centre of the first incision and extending directly downward to a point 
on a level with the inferior angle of the bone (presenting a T-shaped figure). 
The flaps, consisting only of skin and subcutaneous tissue, are next to be re- 
flected backward and forward, when most of the muscles connecting the arm 
with the scapula and the scapula with the body will be brought into view. 
The trapezius must now be detached from its connection with the spine of 
the scapula above, and the deltoid from the same eminence below. Those 
detachments effected, it will be necessary to divide the insertion of the levator 
anguli scapulae, together with the two rhomboid muscles, from the upper 
angle and the vertebral border of the bone. 
At this stage of the operation the posterior scapular artery will be cut, and 
should be immediately secured. Raising the inferior angle of the scapula, 
the surgeon will now be able to sever the origin of the serratus magnus 
and teres major muscles, at the same time separating the latissimus dorsi 
from its connection with the lower angle of the bone. 
* See American Journal of the Medical Sciences, October, 1878. 
f New York Medical Journal for 1878, p. 52. EXCISION OF THE SCAPULA. 
249 
The clavicle may be next detached from the acromion, or, preferably, this 
process may be sawed through posterior' to the acromio-clavicular articula- 
tion, and the latter allowed to remain. 
The last stage of the operation consists in sawing through the neck of 
the scapula by means of a chain or other saw, and removing the bone, thus 
leaving the scapulo-humeral articulation undisturbed. 
If, however, this plan is rendered impossible by the circumstances of the 
case, and it is deemed necessary to take away the bone in its totality, the 
lower end of the scapula should be raised upward in the direction of the 
neck, when the coracoid process can be freed from its muscular and other 
connections, the capsule of the joint can be divided, and likewise the scapular 
muscles, which are connected with the tuberosities of the humerus. 
The Subperiosteal Method.-When the scapula is removed on account 
of caries, the subperiosteal method of Ollier should be adopted. This latter 
operation may be divided into three stages,-the formation of flaps, the 
denudation of the bone, and the disarticulation. 
The first, or formation of flaps, is accomplished by two incisions, the one 
following the line of the posterior border of the scapula 
from its upper to its lower angle, and the second extending 
over the spine of the bone from the acromion process back- 
ward and slightly downward, until it joins the first incision. 
(Fig. 1103.) 
After reflecting the flaps and severing the attachments 
of the trapezius and deltoid from the acromion and spine, 
the operator divides the periosteum over the vertebral 
border of the scapula, and, applying an elevator, commences 
the separation of the periosteum from the infra-spinous 
fossa. When the lower angle of the bone is reached, the 
teres major and latissimus dorsi muscles are detached. 
The elevator is then applied to the under surface of the scapula, raising the 
periosteum from the subscapular fossa, and with it the serratus magnus and 
subscapularis muscles. 
The supra-spinous fossa is next treated in a similar manner, in doing which 
care must be taken not to damage the supra-scapular nerve, where it traverses 
the supra-scapular notch. 
The lower part of the scapula should next be raised, in order that the 
whole of the venter and the anterior part of the bone may be cleared. Here, 
as in the operation first described, if the disease or injury will allow, the 
neck of the scapula may be divided, and the glenoid cavity, with the coracoid 
process, be allowed to remain. 
If this is not allowable, the third and last stage of the operation can be com- 
pleted by disarticulating the acromion process from the clavicle, turning the 
scapula strongly upward, and, after dividing the capsular ligament from below, 
severing the muscular and ligamentous attachments of the coracoid process. 
After the extirpation has been effected, and all bleeding has been controlled, 
the flaps are to be brought together by silver sutures, a drainage-tube having 
been previously inserted in the wound. 
Dressing.-The usual water or carbolized dressing is applied, and made 
secure by means of a spica roller of the shoulder; the hand and arm must be 
kept supported in a sling. 
Even when the extirpation of the scapula has been complete, the arm has 
preserved, to a very extraordinary degree, most of its movements, except 
that of abduction. 
History and Results.-Excision of the scapula, leaving the arm undis- 
turbed, was proposed by Liston in 1819, and first performed by Langenbeck* 
in 1855, in the case of a boy suffering from osteoid cancer. An operation of 
this kind is said to have been performed by Cumming in 1808; but I am un- 
able to establish its verity. In 1850, Gross removed the largest portion of 
Fig. 1103. 
Lines of incision for 
exposing the scapula, 
* Deutsche Klinik, 1855, No. 38. 250 
EXCISION OF SPECIAL JOINTS AND BONES. 
the scapula, leaving only the acromion process and the neck, with the gle- 
noid cavity and the coracoid process. In 1856, Syme removed the scapula, 
and again, in the following year, on account of a tumor involving the bone, 
in a female seventy years of age. The same year (1856) witnessed a like 
operation done by Pirrie. In 1857, Heyfelder* excised, unsuccessfully, this 
bone for caries. Jones, of Jersey, performed this operation for caries in 1858.f 
In 1860 two extirpations of the scapula were done, one by Hammer and the 
other by Schuh. In 1868, Dr. Stephen Rogers, of New York, published a 
tabulated account of 56 cases of this excision, with an important memoir of 
the operation.J Of these, 24 were excisions of at least three-fourths of the 
scapula, 16 of which were reported as having been followed by a good use of 
the corresponding arm, or about 66 per cent. Of 45 cases of partial ex- 
cisions noted by the same author, the death-rate was 22.2 per cent. In 1859, 
Petrequen, of Lyons, excised the scapula, separating the bone from the acro- 
mion process and at its neck. In 1860, Michaux, of Louvain,§ gave an ex- 
tended memoir on this operation, at the same time recording a temporarily 
successful case of his own, in a lad aged fifteen years. In 1861, Walters, of 
Pittsburg, published an interesting case of this excision, in which, as in those 
of Gross, Petrequen, and Michaux, the scapula was extirpated through the 
neck and the acromion process. Wolcott has performed a similar operation. 
These operations were followed by those of Bird, in 1863,-in which the 
head of the humerus and a portion of the clavicle were also cut away at two 
operations; of Hamilton,|| in 1864; of Rogers, in 1867; of Schuppert, of 
New Orleans, in 1868; of Pollock, in 1870; of Esmarch, in 1870; of Steele 
and Michel, in 1871; and of Logan,in 1872. 
To these cases may be added two excisions by Spence, in 1872, one exe- 
cuted the same year by King, also one by O'Grady, and one by Crawford. 
In 1874, Schneider,** of Konigsberg, reported a case in a boy six and a half 
years old, in which death occurred four and a half months after the opera- 
tion from a recurrence of the disease. Following these come the cases of 
Wood, MacCormacff (1875), OmboniJJ (1875), Pean§§ (1877), Gundrum|||| 
(for gunshot), 1877, (1878), Mazzoni,*** Billroth,fff Brigham, 
in 1878, and lastly those of Orlowski§§§ and Mikulicz,|||||| in 
Excluding the cases of Gross, Petrequen, Walters, and Wolcott, which 
were incomplete, there remain 37 cases of total excisions of the scapula, in 
30 of which recovery followed, leaving 5 deaths, and 2 results undetermined. 
The death-rate in these cases is, therefore, 13 per cent. 
Otis has tabulated 49 cases of partial excision of the scapula performed 
during the War of the Rebellion, on account of gunshot injuries. Very few 
of this number could be strictly termed excisions, as in many instances only 
small portions of the bone were picked away through the wound, merely 
enlarging the latter. The terminations of these cases were as follows : 23 of 
* Deutsche Klinik, 1857. j- Med.-Chirurg. Transactions, vol. xlii. p. 7. 
J American Journal of the Medical Sciences for October, 1868, p. 359. 
j/ Gazette Medicale de Paris, 1866 (Nos. 16, 17, 18). 
|| Medical and Surgical Reporter, 1866, vol. xiv. p. 372. 
Richmond Medical Journal, 1872, vol. xiv. p. 131. 
** Berliner Klinische Wochenschrift, No. 31, 1874 (cit. London Medical Record, October, 1874, 
p. 667). 
ff St. Thomas's Hospital Reports, vol. vii., 1876. 
jt Raccoglitore Medico, January 30, 1875. 
Lancet, July 28, 1877. 
Uli American Journal of the Medical Sciences, July, 1878. 
5]Y American Journal of the Medical Sciences, Philadelphia, July, 1878, p. 100. 
*** Gaz. Med. di Roma, vol. iii. No. 6: also New York Medical Journal, 1878, p. 551. 
ftt American Journal of the Medical Sciences, 1878, p. 275, and London Medical Record, March 
15 and May 15, 1878. 
fft Boston Medical and Surgical Journal, April 11, 1878. 
Centralblatt fur Chirurgie, 1878. 
nil'll' Wien. Med. Bl., 1879, vol. ii. p. 45. 
Dr. Kilburne King has twice excised the scapula for malignant disease, once successfully 
and once with a fatal result, but I have not been able to discover whether they were total or partial 
excisions. See Liverpool and Manchester Medical and Surgical Reporter, vol. iv. pp. 68-70. EXCISION IN THE CONTINUITY OF THE HUMERUS. 
251 
the operations were primary, with 6 deaths; 14 intermediary, with 6 deaths; 
2 secondary, with no deaths; and 1 death among the unclassified cases, 
-making in all 13 deaths, or 27 per cent. Of the 36 survivors, 24 were dis- 
charged, and 12 returned to full or modified duty. 
Dr. Von Adelmann, of Dorpat, at the Seventh Congress of the Society of 
German Surgeons, held at Berlin, April, 1878, in a paper* there read, gave 
61 cases of complete extirpation of the scapula, which he had collected from 
various sources, drawing from the analysis conclusions quite favorable to the 
operation. 
It would appear that total excisions of the scapula prove less fatal than 
those which are partial. This conclusion is reached by Bogers, Schneider, 
and Jones. 
In cases of enchondroma, caries, necrosis, and injury, the excision of the 
scapula, entire or in part, comes legitimately within the sphere of operative 
surgery; but when undertaken for the cure of malignant disease the pro- 
priety of such a procedure is very questionable indeed. And this opinion 
is formed after having carefully analyzed the results of operations executed 
for this purpose. 
Excision of the Scapula following Amputation at the Shoulder- 
Joint.-This operation has been practiced eleven times, the operators being 
Hussey, f Rigaud,£ Fergusson (1867), Langenbeck,§ Buck, Busch, Krako- 
wizer, Stimpson, Jeaffreson|| (1873), Soupart,and Deroubaix.** The re- 
sults of these operations were 6 recoveries, 4 deaths, and 1 result unknown. 
Logan,in 1872, removed the scapula, on account of disease of the bone, 
after a previous excision of the head of the humerus, the patient making a 
good recovery. 
Excision in the continuity of the humerus has been performed on account 
of shot or other injury attended by comminution, on account of disease, and 
also for pseudarthrosis. 
Operation.-In excising the humerus, an incision should be made along 
the outer aspect of the arm and through the intermuscular fissure which 
separates the biceps from the deltoid and triceps muscles. At the lower part 
of the arm, the operator must be careful not to get between the brachialis 
anticus and supinator muscles; otherwise the radial nerve will be exposed 
to injury. Hence, in prolonging the incision downward, it is necessary to 
keep close to the external border of the biceps muscle. 
On reaching the bone, the periosteum should be divided, and, by means of 
an elevator, separated from its osseous connections. The diseased humerus 
can then either be pulled away with strong forceps, or, if this cannot be 
readily accomplished, it can be cut away with a chain-saw. 
Few blood-vessels will require the ligature, and the wound must be closed 
by interrupted sutures, a drainage-tube having been previously inserted. 
The entire limb can then be supported either on an internal angular splint, 
or on a leather or a felt trough-splint. The plaster roller, applied by recur- 
rent turns, will also serve the same purpose very well. 
Results and Indications.-During the late American war, excisions for 
shot wounds were much less successful than the treatment by expectancy; the 
death-rate in the former being 28.5 per cent., and in the latter 15.2 per cent.JJ 
Non-union of the bone was a very frequent occurrence after these excisions; 
and the mortality was 12 per cent, greater than that following amputation 
Excision in the Continuity of the Humerus. 
* London Medical Record, May 15, 1878. 
f American Journal of the Medical Sciences, Philadelphia, 1837, vol. xxi. pp. 390-394. 
j Edinburgh Medical Journal, November, 1874, p. 467. 
£ Archiv der Klinische Chirurgie, 1862, B. iii. 306. || Lancet, vol. i., 1874. 
Annales de la Society Medicale de Gand, 1857, xxxv. 
**• Gazette Medicale de Paris, 1866, tom. xxi. p. 277. 
ft Richmond Medical Journal, 1872, vol. vi. p. 144. 
See vol. i. p. 249, Surgical History of the War. 252 
EXCISION OF SPECIAL JOINTS AND BONES. 
of the arm. These facts are sufficient to condemn excision for gunshot 
fractures of the bone. 
Of 169 cases of excision of the shoulder, collected by Professor Heyfeldcr, 
of St. Petersburg, performed as well for disease as for injury, 30 were fatal, 
-a death-rate of 18 per cent. Dr. Bergmann, of Dorpat, has published 15 
cases of this excision, with 3 deaths, or 20 per cent. Hodges gives 50 cases, 
done for disease only, with 8 deaths, or 16 per cent. 
When the humerus is the seat of either acute or chronic necrosis, ex- 
cision will be proper; as it also will be in cases of ununited fractures, after 
other and less dangerous measures for securing the consolidation of the bone 
have failed. 
In every case the periosteum should be preserved, and, when the opera- 
tion is performed for pseudarthrosis, the probability of success will be en- 
hanced by wiring together the ends of fragments. When the periosteum 
has been retained, the reproduction of a new bone answering to the part 
removed may be expected. 
Even when the entire diaphysis has been resected, as in Langenbeck's, 
Ollier's, and Wilkes's cases, a new bone has been formed. Dr. Cutter, of 
New Jersey, in a case of necrosis, excised not only the entire humerus, but 
also the upper extremity of the radius and ulna, obtaining, finally, a reason- 
ably good arm. 
When, however, the disease transcends the limits of the diaphysis, making 
it necessary to include the epiphysis in the resection, and when the perios- 
teum cannot be preserved, it will be better to amputate. For otherwise the 
limb will be left hanging like a flail, and will prove an incumbrance rather 
than a useful member of prehension. 
Excision of the Bones of the Forearm. 
Excision of one or of both bones of the forearm may become necessary 
on account of necrosis, myeloid and other tumors, and in cases of ununited 
fracture. The operation has been executed for gunshot injury, but with poor 
results. 
Operation.-If the ulna is to be removed, the incision should be made 
along its inner border, entering the fissure between the flexor and extensor 
carpi ulnaris muscles. 
When the radius is to be the subject of operation, the bone is most satis- 
factorily exposed by a cut made along its posterior surface, external to the 
supinator muscles. 
After incising the periosteum and peeling it away from the bone, the latter 
may be divided, either by a pair of strong cutting pliers or by the chain- 
saw. 
If the excision is partial, and limited to one bone, the probability of non- 
union is much greater than when both bones are resected. 
One bone may be wholly removed and yet a useful forearm remain. 
Dressing.-After the operation is completed, and the wound is closed by 
interrupted sutures and covered with a carbolated oil dressing, the limb 
should be lightly secured to an internal angular splint. 
The results following formal excisions in the continuity of the radius and 
the ulna, during the late civil war, for shot wounds, were so uniformly bad 
that the operation merits unqualified condemnation. In 40 partial primary 
excisions of both the radius and the ulna, 34 patients recovered with useless 
limbs, and a number of these only after amputation. 
History.-Heyfeldcr states that Bilguer, Saint-Hilaire, and Fricke were 
among the first to resect portions of the radius and ulna in their continuity 
for shot injuries. In this country, Dr. Fahnestock, of Pittsburg, in 1840, 
recorded the first instance of excision of the shaft of the radius on account 
of shot injury.* 
* American Journal of the Medical Sciences, 1840, vol. xxvi. p. 91. EXCISION OF THE BONES OF THE LOWER EXTREMITY. 
253 
A resection of the shaft of the ulna, for disease, is ascribed by Velpeau 
to Scultetus, as early as 1675. 
Partial excisions of these bones, on account of ununited fractures, were 
done by Fricke, in 1828, by Holscher. in 1830, and by Dr. Thomas Harris, 
U.S.N., in 1833. Similar operations were executed for compound and com- 
pound comminuted fracture, by Hublicr, in 1829. 
In 1853, Carnochan resected the entire ulna. Similar operations were per- 
formed by Mr. Jones, of Jersey, England, and by Dr. Muscroft, of Cincinnati. 
Butt, of Portsmouth, Virginia, removed the lower three-fourths of the ulna, 
in 1825, with an excellent result. Bell, of Edinburgh, and Hutchison, of 
New York, have excised the entire ulna. Rklitsky, Surgeon-in-Cbicf of the 
Morskoy Hospital, St. Petersburg, in 1837, removed the whole of the dia- 
physis of the radius. A similar operation was performed by Erichsen and 
by Carnochan, in 1854. Compton, of New Orleans, in 1853, excised portions 
of the radius and the ulna in its entirety. All of these cases recovered, it 
is said, with very useful hands. 
A number of cases have been recorded in which the lowei' extremities of 
both the radius and the ulna have been removed on account of caries or morbid 
growths, leaving a useful hand. Among these may be mentioned those of 
Mr. Hancock and of Mr. Morris. In one case Erichsen removed the elbow- 
joint and the greater part of the radius at the same operation, and Wil- 
liamson has excised the entire ulna along with the elbow-joint. 
In a case of scrofulous disease, Professor Gross resected the upper half of 
the radius along with the external condyle of the humerus. 1 have made 
several partial excisions of these bones on account of compound fractures, 
caries, and morbid growths, and with the most satisfactory results. 
Excision of the Bones of the Lower Extremity in their Continuity. 
Excision of the Femur.-Partial excisions of the femur, in cases of com- 
pound comminuted fractures, and for pseudarthrosis, have occasionally been 
executed. Such operations are attended with great danger; and, except 
when done for compound comminuted fractures, they should be discarded 
from surgical practice. The removal of the shaft of the femur to any great 
extent, unless the union of the remaining ends could be secured, would 
render the limb both useless and an incumbrance. 
Excision of the Trochanter Major.-The trochanter major has, in a 
few instances, been excised when attacked by necrosis; and when the disease 
is limited to this portion of the bone-a very rare occurrence-the operation 
is entirely proper. The first excision of this kind was done by Tenva, as 
early as 1798; it has been repeated in England by Teale and Fergusson, in 
France by Velpeau, in Germany by Textor and Heyfelder, and in America 
by Parker. 
Operation.-A director should be passed through one of the sinuses down 
to the diseased bone, when, by enlarging the opening, the necrosed portion 
may be extracted. If a more formal procedure is required, as when the fis- 
tulous orifices open upon the surfaces of the thigh, remote from the seat of 
the disease, an incision may be made parallel with and along the posterior 
border of the process, when, by clearing away the soft parts from the tro- 
chanter major, the necrosed portions can be reached by the bone forceps or 
gouge. 
Before closing the wound the drainage-tube should be introduced, and its 
end brought out at the lower angle of the incision. 
Excision of the Patella.-The patella, though requiring removal in cases 
of knee-joint excision, is rarely independently affected with disease. 
The operation, however, has been practiced in a number of cases on account 
of caries, compound comminuted fracture, and also for shot injury. 
Heyfelder's collection embraces 11 cases, with 9 recoveries and 2 deaths. 254 
EXCISION OF SPECIAL JOINTS AND BONES. 
In 3 of these cases the excision was partial, and among the recoveries were 
3 that demanded subsequent amputation. About 45 per cent, of these opera- 
tions, therefore, failed. 
Two cases of partial excision of this bone, following compound comminuted 
fracture, were done in the Pennsylvania Hospital, with the result of 1 
recovery and 1 death. 
Results.-A case of the removal of a necrosed patella was reported by M. 
Thirion, of Namur, in 1829. In 1860, Dr. 0. B. Knodc, of Missouri, excised 
the whole patella for necrosis after a fall, with the result of a good and useful 
limb.* Later, Mr. Wood, in a case recorded by Dr. Kelly,f removed the 
entire patella after it had become loosened. In 1876, Mr. Gay, at the Great 
Northern Hospital, excised a patella on account of necrosis, with a good re- 
sult. | Heyfelder has discussed 11 cases of excision of the patella, 5 of which 
were for caries, 3 for fracture, and 3 for shot injury. In 8 of these the ex- 
cision was complete. Of the entire number, 6 recovered without amputation, 
3 recovered with amputation, and 2 died,-a death-rate of 18.18 per cent. 
Excision of the Bones of the Leg. 
Excision of the Tibia.-The objections which apply to the excision of the 
femur may with almost equal force be urged against a similar operation on 
the tibia. 
The weight of the body is transmitted to the foot chiefly through this 
bone; and, should any considerable portion of its shaft be excised, inde- 
pendent of the fibula, the gap between the remaining portions of the bone 
would fail to be filled with new bone, thus rendering the limb incapable of 
supporting the superincumbent weight. 
The subperiosteal excision of the tibia, though successful in a case reported 
by Mr. Heath,§ in which the entire removal of the tibia was followed by the 
reproduction of another bone, is an operation of great uncertainty. I have 
seen a partial operation of this kind done, but without any subsequent 
deposition of osseous matter. 
Whenever partial excision of the tibia is contemplated, either in a case of 
false joint or in one of compound comminuted fracture, it should always bo 
accompanied by the removal of a corresponding portion of the fibula. By 
this means a good bony union may be expected to follow. 
Operation.-This will be most conveniently performed by a longitudinal 
incision over the spine of the tibia, and, after carefully isolating the part of 
the bone to be excised from its periosteal and othci' connections, using the 
chain-saw to remove the affected part. 
Dr. S. W. Gross has analyzed 172 cases of excision of the bones of the leg 
for gunshot injuries, 135 of which recovered and 35 died,-a death-rate of 
20.34 per cent. In 19 of the 172 cases, portions of both the tibia and fibula 
were removed, with a result of 4 deaths,-a mortality of 21 per cent. Ex- 
cision of a part of the tibia was done in 72 cases, with 15 deaths,-a death- 
rate of 20.8 per cent.,-while a similar operation on the fibula, in 81 cases, 
resulted in 16 deaths,-a death-rate of 19.7 per cent. The death-rate in all 
these cases (20.34 per cent.) exhibits a mortality considerably less than that 
following amputation of the leg. 
In estimating the value of this excision, however, it is necessary to take 
into account more than the simple recovery. The inquiry should extend 
also to the subsequent condition of the limb. How many cases, foi- example, 
were followed by non-union, caries, and necrosis? and what number would 
be likely to demand amputation at some future period? If these points 
were fully ascertained, the operation of even partial excision of the tibia 
* North American Medico-Chirurgical Review for 1860. 
f Transactions of the Pathological Society of London, vol. xxii. 
j Lancet, 1876, vol. ii. p. 322. 
§ Transactions of the Clinical Society, London, 1877. EXCISION OF THE BONES OF THE LEG. 
255 
would have a very limited application. It would be confined chiefly to 
disabling deformities, and occasionally to a case of false joint. 
Heyfelder gives 125 cases of excision of the tibia, performed on account 
of fractures, disease, pseudarthrosis, and deformities, 104 of which recovered 
and 21 died,-a death-rate of 16.8 per cent. Of the 104 recoveries, 97 were 
regarded as having useful limbs. 
Excision of the Fibula.-The fibula, having a different functional position 
in the leg from that of the tibia, may be removed, in 
whole or in part, without entailing any serious disability 
on the limb. It is desirable, however, when it is pos- 
sible, that the malleolar process should not be disturbed, 
as its presence tends to prevent subsequent eversion of 
the foot. 
The causes which may indicate the removal of the 
fibula, partial or entire, are necrosis, compound com- 
minuted fracture, pseudarthrosis, and deformity. 
Operation.-This is readily executed by making a 
longitudinal incision along the outer aspect of the bone, 
and, when feasible, shelling it out from its periosteum; 
after which the diseased can be separated from the 
healthy part by the bone pliers. 
In order to prevent the foot from being drawn out- 
ward by the action of the peroneal muscles, a splint 
must be placed upon the inner side of the leg; and, for 
some time after, it will be necessary for the patient to 
wear a shoe with steel supports attached, and extending 
above the knee. (Fig. 1104.) 
The proposal to excise the fibula originated with 
Desault, and the operation was first performed by 
Percy. Seutin, Bedard, Malgaigne, and other surgeons 
have executed similar resections. Dr. Jackson, of Chicago, and Erichsen 
have each removed the entire fibula with success. These last two operations 
were done for disease,-the first in the case of an adult female, and the 
second in a child six years old. 
Fig. 1104. 
Apparatus to be worn after 
excision of the fibula. 
Excision of the Tarsal Bones.-Any one of the tarsal bones may be the 
subject of disease or of injury for which excision will be required. Not all 
of these bones, however, are equally subject to disease. The astragalus, the 
os calcis, and the scaphoid are more frequently involved than the others. 
Their position and function necessarily expose them and their articulations to 
considerable concussion and strain. 
Excision of the Astragalus.-This bone, participating in the ankle ar- 
ticulation, may be attacked with caries as a sequence of a synovitis extending 
to its structure. Or it may be dislocated from its connection with the bones 
of the leg, either with or without an external wound, and become irreducible. 
In either condition-of disease or of accident-its excision may become 
necessary. 
When disease extends to the astragalus from the other parts of the ankle- 
joint, it will not, generally, be necessary to make more than a partial ex- 
cision of the bone, especially if an early operation is performed. For, in all 
probability, only a very limited portion of its structure (that immediately 
underlying the articular cartilage) will have become carious. But when 
the reverse is the case, and the inflammatory condition commences in the 
astragalus itself, it will be safer to extirpate the entire bone. Any por- 
tion which might be allowed to remain w'ould, most probably, become 
diseased, and only serve to propagate the inflammation to the contiguous 
synovial membrane, and ultimately to the other bones with which it is 
associated. 256 
EXCISION OF SPECIAL JOINTS AND BONES. 
The sinuses usually present in caries of the tarsal bones will, when ex- 
plored with the probe, reveal the affected piece. 
Operation.-A. semilunar incision should be made across the outer and 
anterior surface of the ankle, taking care to avoid cutting the extensor ten- 
dons of the foot or the dorsalis pedis artery. The former being carefully 
raised and held aside, the anterior extremity of the astragalus will be 
exposed. 
With a strong pair of cutting pliers the bone should be divided through 
its neck, and, after detaching the head from its connection with the scaphoid, 
it may be drawn away by the lion forceps. The removal of this piece gives 
room for further operations. 
The body of the bone must now be seized with the forceps, and while 
being twisted from its bed its ligamentous connections should be divided by 
means of a strong, blunt-pointed knife, observing to keep the latter in close 
contact with the piece to be removed, in order to avoid inflicting any injury 
on either the posterior tibial or the plantar arteries. 
If the substance of the bone is much involved, it will crumble dowm under 
the grasp of the forceps, rendering the operation both tedious and difficult. 
In such cases the gouge will greatly facilitate its removal. 
After the diseased piece has been extracted, the articulating extremities 
of the tibia and fibula must be carefully examined, to be assured of their 
soundness. If found to participate in the disease, it will be necessary (pro- 
vided the affected ends cannot be attacked from the wound already existing) 
to prolong the external incision upward behind the external malleolus, to 
dissect out the peroneal tendons from their grooves in the fibula, and to cut 
away the inferior extremity of the fibula. If the foot be now strongly ab- 
ducted, the internal malleolus may be divided wTith the pliers, and be very 
carefully dissected away from its ligamentous connections. 
Should it be necessary to excise any more of the bones of the leg, it can 
be done by the gouge, or by causing them to protrude through the external 
wounds, using for this purpose the chain-saw. 
Dressing.-After removing the astragalus and thoroughly cleansing the 
wounds, the bones of the leg should be brought in contact with the upper 
surface of the os calcis; a drainage-tube should be introduced, and the edges 
of the incision closed by the interrupted suture and protected by a dressing 
of carbo la ted oil. 
A splint similar to that directed for excision of the ankle will answer 
equally well for the support of the foot and leg during the subsequent 
treatment. 
The operation for the removal of the astragalus in cases of dislocation of 
the bone in which the latter has become carious, or in which, by its abnormal 
position, it induces ulceration of the overlying soft parts, is a comparatively 
easy task, requiring for its accomplishment little more than exposure and 
traction by the bone forceps. 
.Results.-Mr. Hancock has given 109 cases in -which complete excision 
of the astragalus was performed. Of this number, 64 were treated for com- 
pound dislocation, 20 for simple dislocation, 11 for disease (of which 10 
were for caries), and 4 for compound fracture, while for 10 the causes were 
not stated. Of the 64 treated for dislocation, 5 were complicated with frac- 
ture, and 4 with compound fracture. The results attending these opera- 
tions were as follows: of the 64 excisions for compound dislocation, 50 re- 
covered with good and useful limbs; 1 underwent secondary amputation of 
the leg, and recovered; 11 died, of whom 1 had undergone secondary ampu- 
tation ; and of 2 the results are not given. Of the 4 operated on for compound 
fracture, 3 recovered with good and useful limbs, and 1 died. Of the 20 treated 
fbr simple dislocation, in 4 (of whom 1 died) the bone was allowed to remain 
for a month ; in 1 the bone remained for nineteen weeks; in 7 (2 of whom 
died) the bone was removed immediately; in 2 the bone was removed with 
a secondary caries, but at what period is not stated; in 6 the period of re- EXCISION OF THE OS CALCIS. 
257 
moval was not given. Of these 20,14 recovered with good and useful limbs, 
3 died, and in 3 the results are missing. Of the 10 upon whom the excision 
was done for disease (caries), 6 recovered with good and useful limbs; 1 un- 
derwent secondary amputation two years afterwards, and recovered ; 1 died ; 
in 2 the result was not stated. So that of 109 cases, 70 recovered with good 
and useful limbs; 16 died (a death-rate of 14.6 per cent.), including 1 of two 
cases which submitted to secondary amputation; and in the rest the result 
■was doubtful.* 
The cases collected by Poisnot number 144, of which 26 proved fatal,-a 
death-rate of 18 per cent. Mr. Gant records 14 cases of complete excision of 
the astragalus for disease (13 of which were for caries). Of these 14, 9 re- 
covered or did well, 2 underwent secondary amputation and recovered, in 2 
the result was not reported, and 1 died.f The proportion of success in these 
cases was, according to these data, about 60 per cent. 
The removal of the astragalus has been performed a number of times suc- 
cessfully in Philadelphia, the operators being Packard, Morton, Brinton, and 
the author. Dr. Kane removed both bones in a patient at the same time, and 
with a good result. Mr. Holmes, in his work on " The Surgical Treatment 
of Children's Diseases" (p. 491), has discussed excision of the astragalus, 
scaphoid, and tarsus, at some length. 
History.-The removal of the astragalus was first performed by a surgeon 
of Duisburg, in 1582, as recorded by Fabricius Hildanus, and again in 1646, 
by Severin. This last case, however, was a partial excision. In England, 
in 1792, the first incomplete resection of this bone was made by a surgeon 
named .Ramsay. Cases of complete excision of the astragalus have been re- 
corded in England by Brusk, in 1850, by Erichsen, Statham, and Holmes. 
Excision of the Os Calcis.-The excision of the calcancum may be required 
on account of caries, necrosis, or comminuted fractures. The operation is 
one of much less difficulty than that of excising the astragalus. This bone 
is more frequently attacked by caries than any other portion of the tarsus,- 
a fact due, no doubt, to its functional position, by which it is necessarily very 
much exposed to contusions. The extent of cancellated tissue in its struc- 
ture may also predispose it to inflammatory disease. In many instances of 
disease it will be necessary to excise portions of this bone, and this can be 
best accomplished by the use of the gouge. 
Operation.-The incision should be planned in such a manner that the 
cicatrices following the healing process shall not be in a position to be sub- 
jected to pressure. Hence the operation of Mr. Erichsen possesses advan- 
tages which should entitle it to general acceptance. By this method, the 
patient having been placed on his breast, an incision is commenced about 
three-quarters of an inch behind the tuberosity of the metatarsal bone of the 
little toe, and carried back around the heel, and along the inner side of the 
foot, terminating opposite the point of beginning. 
It is not necessary, however, to carry the incision as far forward on the 
inner as on the outer side of the foot; it may stop three-quarters of an inch 
short of that point. Care must also be observed not to divide the tendon of 
the peroneus longus muscle as it passes through its groove in the cuboid bone, 
half an inch behind the metatarsal bone of the little toe. 
The flap thus circumscribed by the horseshoe-shaped incision is next to be 
raised cleanly from the bone and turned forward over the anterior part of 
the sole of the foot. 
A vertical incision is next to be made over the tendo Achillis, terminating 
in the horizontal one; the integument and the subcutaneous tissue are to be 
reflected to either side, and the tendon shaved off from its insertion upon the 
bone. 
The knife is now made to enter posteriorly, and is carried along the upper 
* Lancet, August 5, 1871, p. 185. 
f New Sydenham Society's Biennial Retrospect for 1865-66, p. 281. 
VOL. II.-17 258 
EXCISION OF SPECIAL JOINTS AND DONES. 
surface of the calcaneum until the interosseous ligament, connecting the bone 
with the astragalus, is reached and divided. (Fig. 1105.) 
When this is effected, the os calcis can be drawn backward and separated 
from its lateral attachments by keeping the edge 
of the knife applied closely to its surface. If this 
is carefully executed, the long peroneal tendon 
need not be damaged. 
The last step of the excision consists in severing 
the calcaneo-cuboid articulation, after which the 
bone can be removed in its entirety. 
Holmes advises that the incision should be made 
on a level with the upper surface of the os calcis, 
commencing at the inner edge of the tendo Achillis. 
and, after extending around the heel, should be 
prolonged a short distance in front of the calcaneo- 
cuboid articulation, dividing in its course the tendo 
Achillis. From the anterior termination of the 
first incision a second is carried across the sole of 
the foot, find ends at the outer border of the 
grooved internal surface of the os calcis. After 
reflecting the flaps, the os calcis should be dis- 
articulated from the cuboid, and afterwards from 
its connection with the astragalus, the surgeon 
using the lion forceps to twist the diseased bone 
from its bed and thus to aid in its detachment. 
Tealc and Page prefer an incision similar to that 
employed by Syme in his amputation at the tibio- 
tarsal joint. I can see no advantage possessed by 
these operations over that practiced by Erichsen, 
save in the possibility of avoiding the chief trunks 
of the plantar vessels, by the plan proposed by 
Mr. Holmes. 
The dressing will be the same as that employed 
in excisions of the ankle-joint. 
Southain and Laird, of Manchester, adopt a 
single incision, beginning as that of Holmes, and terminating over the pero- 
neal tubercle of the calcaneum. I have myself, by a single incision, very 
satisfactorily exposed the bone in cases of incomplete excision. 
Ollier describes a subperiosteal excision of the os calcis, which is performed 
by making one incision from the inner side of the tendo Achillis around the 
heel to the cuboid bone, and a second incision vertically along the side of 
the tendo Achillis into the first; after which the periosteum is raised by an 
elevator, including the tendons. Holmes has performed this operation once. 
He does not speak very favorably as to the result, but thinks the operation 
worth a trial. Nor are its claims to professional confidence supported by 
statistics. On subperiosteal resection of the calcaneum much has been written 
in the Gazette Hebdomadaire for 1876, pp. 497, 507, and 527. 
Results.-Dr. Burrall, of New York, summarizes 48 cases of excision of 
the entire os calcis, with 33 good results.* Of the whole number, 38 were 
done for caries, 1 for caries and necrosis, and 1 for necrosis, with 7 subsequent 
amputations. Of 21 of these cases, collected by this writer (14 of which 
were strumous and 3 healthy), 17 were successful, 1 died, and 1 underwent sec- 
ondary amputation, the proportion of success amounting to about 80 per cent. 
In 12 similar cases, reported by Mr. Greenhow,f of England, 10 were suc- 
cessful; in 1 of these, however, the patient subsequently died of phthisis, and 
in 1 the foot, when last seen, was unfit for use. These 12 cases are included 
in Dr. Burrall's compilation of 48. 
Fig. 1105. 
The os calcis exposed by the plantar 
flap. 
<if Bellevue and Charity Hospital Reports for 1870. 
f British and Foreign Medico-Chirurgical Review, July, 1853. EXCISION OF THE CALCANEUM AND ASTRAGALUS. 
259 
Mr. Hancock has collected 38 cases of partial excision of the os calcis on 
account of disease; 23 of this number recovered, 1 died, and the results of 
the remaining 15 were not ascertained. Among the 23 recoveries, 13 required 
secondary excision, and 2 amputation. The same author has analyzed 34 
cases of total excision of the calcaneum, 29 of which were successful, 1 died, 
and in 4 the termination was not ascertained. 
M. Rigaud, of France, states that he has executed 11 entire resections of the 
os calcis, in cases where the bone was entirely diseased, with 10 good results.* 
Professor Polaillon gives 55 carefully-digested cases of extirpation of the 
calcaneum for caries and necrosis. This author estimates that of this number 
there were 16 failures (6 failures to restore usefulness to the foot, 7 cases in 
which amputation became necessary, and 3 deaths from the operation), with 
39 favorable The percentage of failures, therefore, is 29.09. The 
number of failures in cases between the ages of twenty and thirty years was 
very large, viz., as 7 to 9. The most propitious ages for the operation were 
under ten and over thirty years. Only one case depended upon syphilis. This 
French investigator remarks, " Operators always take less pains to make 
known their failures than their successes, especially in a mooted operation 
so little practiced as this," contending also that as this operation is performed 
as a substitute for amputation, and with the object of securing a good and 
useful limb, in cases where less than this is attained the excision should be 
set down as " bad." 
The operation, so far as my own experience and observation extend, has 
been followed by the most satisfactory results in all cases in which the disease 
was limited to the os calcis. 
M. Vincent, a pupil of Ollier, in a work on this subject,J analyzes 23 
operations for the entire removal of the calcaneum. Those executed by the 
subperiosteal method alone gave reproductions of the calcaneum and pro- 
cured the finest results as regards the form and function of the foot. The 
fatal cases, however, M. Vincent finds were more numerous when the sub- 
periosteal method was employed than when the old was practiced, particularly 
in patients over twenty-five years of age. 
Excision of the Calcaneum and Astragalus.-As disease of the tarsal bones 
very frequently commences in the articulation between the os calcis and the 
astragalus, it occasionally happens that both become simultaneously involved, 
and may demand removal. 
Operation.-When it is proposed to excise both the calcaneum and the 
astragalus, an incision should first be made similar in all respects to that di- 
rected by Erichsen fbr the removal of the former bone, after which a second 
is required, running vertically along the side of the tendo Achillis and joining 
the first incision. 
The tendo Achillis is next divided. Afterwards the three flaps are to be 
dissected up and reflected,-the plantar one forward, and the two others 
upward and outward. 
The external malleolus being exposed, the lateral ligament is next to be 
divided, and the lower end of the fibula cut through with the bone pliers and 
dissected out. By strongly abducting the foot, the internal lateral ligament 
may be divided, inside of the joint, with a blunt-pointed bistoury. In doing 
this, great care must be exercised that the posterior tibial artery be not 
wounded. 
From the same side, the internal malleolus can bo severed with the bone 
pliers; after this the bones can be separated from their connections with the 
scaphoid and cuboid and be removed. 
This operation was performed by Mr. Wakely,§ in 1847, at the Royal Free 
Hospital. It has also been done by .Dr. Morton (in a case admitted into the 
# Gazette Hebdomadaire, No. 33, 1875. 
f Archives Generales de Medecine for September and October, 1869. 
j Vincent, De 1'Ablation du Calcaneum, Paris, 1876. g Lancet, July, 1848. 260 
EXCISION OF SPECIAL JOINTS AND BONES. 
Pennsylvania Hospital for injury), by Dr. Whitehill, and by Bradford, of 
Kentucky. 
History.-The first partial excision of the calcaneum was probably executed 
by Formius, in 1669, for the extraction of a ball imbedded in the bone. In 
1814, Monteggia made the first total excision of the calcaneum; and in 1837 
a similar operation was performed by M. Robert, of Prague. In 1848, Mr. 
Hancock removed the calcaneum, which was the first operation of the kind 
reported in England ; and this was repeated by Mr. Greenhow, of Newcastle, 
England. Since 1848 it has been done many times by different surgeons. 
Excision of the Cuboid, Scaphoid, and Cuneiform Bones.-Excisions of these 
bones, individually, may be required on account of disease or injury. The 
operation can be easily accomplished by exposing the affected piece from the 
dorsal surface of the foot, taking care to push aside any tendon that may be in 
the course of the incision, and then employing the gouge to remove the bone. 
The operation will be preferable to the amputation of Chopart, and may 
be done with a favorable result. If it should fail, the probable success of a 
future amputation is not in any way diminished. 
All of these bones have been removed, first by Professor Bigelow, of 
Boston, in 1855, and afterwards by Mr. S. Key, leaving the astragalus and 
calcaneum posteriorly, and the metatarso-phalangeal bones anteriorly, with 
a highly favorable result. 
Results.-Conner has collected 35 cases of excision of portions of the tarsus, 
25 of which were successful, 5 proved unsuccessful, and 5 died,-a death-rate 
of 14.2 per cent. 
When several of the tarsal bones in front of the os calcis and astragalus 
are involved in disease or injury, a Chopart or Pirogoff amputation will be 
preferable to excision. 
Excision of the Metatarsal Bones.-The metatarsal bones may be excised 
either partially or entirely. 
They are best exposed by an incision made over their dorsal surface, the 
tendons being raised and held out of the way. 
By the use of the pliers the bone can be divided, and afterwards dissected 
out with a blunt-pointed bistoury, so as not to endanger the vessels beneath. 
Partial resection of the fourth metatarsal bone for caries was performed 
by the elder Moreau in the year 1788 (he removed the base of the bone); 
by Textor, in 1822, a similar operation was done for caries of the fifth meta- 
tarsal bone. 
Mr. Butcher has described a case of excision of the metatarsal bone of the 
great toe,* with recovery and perfect use of the foot. 
Excision of the Toes.-The phalanges which admit of excision are the meta- 
tarsal extremity of the proximal phalanx of the great toe, and the ungual 
phalanges. 
The removal of an intermediary phalanx would render the toe utterly use- 
less, and should not be practiced. 
Results.-In 1863, Mr. Burford Norman, of Southsea, England, in a case 
of necrosis involving the distal phalanx of the great toe of a lad, instead of 
amputating the toe at the joint behind the nail, dissected the integuments, 
nail included, away from the phalanx, and cut the latter through by the 
forceps, behind the seat of exostosis.f The patient recovered with a good 
toe and a good nail. A case of resection of the metatarso-phalangeal joint 
of the great toe was reported by Mr. Butcher in the Dublin Journal for 
1859, done for caries in a girl aged eighteen, with success. Mr. Hancock has 
reported 5 other successful excisions of this joint.J 
* Butcher's Operative and Conservative Surgery, p. 355. 
t Hancock on the Operative Surgery of the Foot and Ankle-Joint, p. 451, London, 1873. 
j Hancock's Anatomy and Surgery of the Human Foot, pp. 448, 449. CHAPTER XIV. 
CONSIDERATION OF SUBJECTS CONNECTED WITH MINOR 
SURGERY.-ON THE USE OF THE KNIFE.-VENESECTION. 
4 
Positions of the Knife.-It is not only necessary that the surgeon should 
possess a steady hand to direct the movements of the knife, but it is also 
desirable that he should cultivate ease, grace, and elegance in executing these 
movements. 
The use of the scalpel or bistoury has been reduced to certain arbitrary 
positions. The French make six of these positions. In enumerating them 
I shall employ a different (and more natural) order from that usually 
adopted. 
First Position.-In this position, the knife is held like a writing-pen, being 
grasped between the thumb and the index and middle fingers, just where the 
blade and the handle of the instrument join, while the hand is supported on 
the outer side of the little and the ring finger. This is the most common 
manner of holding the instrument; and in making incisions the movements 
are chiefly executed by the thumb and fingers alone. (Fig. 1106.) 
Fig. 1106. 
Fig. 1107. 
First position. 
Second position. 
Second Position.-The second position is nearly the same as the first,- 
the edge being reversed, that is, directed from, not towards, the operator. 
(Fig. 1107.) 
Third Position.-In the third position, the knife is held much after the 
manner of a carving-knife. That is, the point where the handle and the 
blade of the knife join is embraced between the thumb and the middle finger, 
the handle being concealed from 
view in the palm of the hand, and 
surrounded by the ring and the 
little finger, while the index finger 
is extended, and rests on the back 
of the blade of the instrument. 
(Fig. 1108.) The knife is much 
employed in this position in cutting 
down upon large growths, where 
free, bold incisions are allowable. 
The amputating knife, as used in the formation of musculo-cutaneous flaps 
by transfixation, is held in the same manner, the blade being on its flat. 
Fourth Position.-The knife is held in a manner similar to the third, only 
with the edge reversed and the index finger less extended. The position is 
Fig. 1108. 
Third position. 
261 262 
ON THE USE OF THE KNIFE. 
a very common one when dividing layers of tissue on the director,-the knife 
being pushed from, instead of towards, the operator. (Fig. 1109.) 
Fourth position. 
Fifth Position.-In the fifth position, the knife is held between the 
thumb and the index and middle fingers, with its edge looking upward, and 
its point directed towards the operator,-a position much used when dividing 
fasciae on the director. (Fig. 1110.) 
Sixth Position.-The knife is held like a violin bow,-between the thumb 
and the fingers,-all parts of the scalpel being exposed. This position is one 
which answers well for delicate touches, as in cutting small shreds of fascia. 
(Fig. 1111.) 
The knife, to be used with the greatest precision and safety, should possess 
Fifth position. 
Sixth position. 
a keen edge, so that the tissues can be penetrated with the least possible 
pressure. If the operator is obliged to apply much force in order to divide 
the soft parts, the instrument may unexpectedly go farther than was designed, 
and, in regions beset with important vessels or nerves, might inflict irreparable 
evil. 
The handle of a scalpel or bistoury should be of good size, and entirely 
smooth. The file-like or roughened surface so often ibrmed by the cutler is 
objectionable on the grounds of cleanliness and safety. It is not improbable 
that disease may be communicated from infectious matters which lie con- 
cealed in these little grooves. For this reason the greatest care should be 
observed thoroughly to cleanse and disinfect all instruments after using 
them. This is best done by immersing them in a carbolic acid bath after 
every operation, and, before restoring them to their place or case, having 
each article smeared over lightly with cosmoline,- a precaution which 
effectually prevents oxidation or rust. 
Manner of Dividing Parts.-The edge of a knife, however sharp, must 
operate as a saw, and consequently will drag before it the skin, which is, 
usually, very movable, and will thus change the relation of the integument 
to the subjacent parts and render the incision less precise than it should 
be. To prevent this, the integument should be fixed or slightly stretched by 
the thumb and fingers of the surgeon, placed on each side of the point where 
the cut is to begin. (Fig. 1112.) 
In order that the incision shall have the same depth from its commence- 
ment to its termination, the point of the scalpel or bistoury, when held in MANNER OF DIVIDING PARTS. 
263 
the first position, should be entered nearly perpendicularly to the surface of 
the skin, then brought to an angle of about forty-five degrees while the cut 
Fig. 1112. 
Skin fixed while an incision is being made. 
is being prolonged towards the person of the operator, and be finally brought 
again to the perpendicular. 
The division of the deeper tissue planes should be made parallel with that 
in the skin, and in most instances of the same length. It is a good rule, es- 
pecially in all deep operations, to make the external incision lengthy rather 
than short. It not only gives a more satisfactory view of the parts, but in 
no way interferes with their rapid repair. As the skin is the most sensitive 
tissue, its division, especially when the patient is not undei* the influence of 
an anaesthetic, should be made by a rapid stroke or sweep of the knife, 
without removing the blade from the part until it has traversed the entire 
length of the contemplated cut. Short cuts are to be avoided, except when 
the bistoury is approaching a dangerous locality. 
Incisions may be made from without inward, or from within outward. 
When the latter plan is pursued, a fold of the integument is raised between 
the thumb and fingers, and a sharp-pointed bistoury pushed through its base 
and made to cut out. This method is sometimes practiced in dividing the 
layers over a strangulated hernia. The division will be made with greater 
precision and facility if the fold of integument is held by both the surgeon 
and an assistant, their fingers being a short distance apart. 
In all operations in important surgical regions, after the division of the 
skin the deeper layers should be raised upon a director, as a prudential 
measure, before being incised; and each layer of tissue should be carefully 
inspected before its division, so as to make sure that no important vessel, 
nerve, or other structure shall be unwittingly severed. 
Whenever tissues can be separated without cutting, the handle of the 
scalpel, the director, or the fingers of the surgeon should be used instead of 
the knife. 
In planning incisions, attention must be given to direction and locality. 
When made in the direction of, or parallel to, the course of muscular fibres 
which may lie beneath, the subsequent approximation and retention of the 
edges of the wound will be favored. This is a very important consideration 
in operations done on the face. If not observed, the facial expression may 
be seriously altered. As to the locality of incisions, when feasible, it is de- 
sirable that they should be so made that the resulting cicatrix will be in 
shade, or out of view, as, for example, in removing the inferior maxillary 
bone, immediately beneath the base of the jaw; or, in excisions of the meta- 
carpal bone of the thumb, along the line of junction between the dorsal and 
palmar aspects of the skin of the hand. 
In operations requiring the formation of flaps, as in the removal of large 
morbid growths, or in amputations, while it is necessary that there shall be 
an ample extent of tissue preserved for closing the wound or covering the 
stump without the least tension of the flaps, it is also proper that there shall 
not be any great redundancy, as it tends rather to defeat than to favor rapid 264 
ON THE USE OF THE KNIFE. 
healing, by allowing pockets to form beneath for the reception of purulent 
and other inflammatory formations. The great elasticity of the skin, and 
its consequent retraction, must be duly considered in estimating the amount 
of flap necessary in a given operation. 
Form of Incisions.-The form of an incision must be determined by the 
peculiarities and necessities of the operation. Under the head of simple in- 
cisions are included those which consist of a single line, and these may be 
linear or straight (Fig. 1113); curvilinear, like the italic letter S (Fig. 1114) ; 
elliptical (Fig. 1115); or semilunar (Fig. 1116). These forms of the simple 
Fig. 1115. 
Fig. 1116. 
Fig. 1113. 
Fig. 1114. 
incision are adapted to the removal of tumors in which it is not necessary 
to take away any redundant integument. They are also well suited for the 
exposure of blood-vessels, as in ligation of the arteries, for operations for 
strangulated hernia, and for uncovering the skull in trephining. 
The compound incisions are formed by two or more lines. Thus, there is 
the ellipse (Fig. 1117), in which two or more curvi- 
linear cuts are made to join at the extremities, 
and which is adopted in all operations requiring 
the removal of an excess of skin, as in excision of 
the mammary gland. There are also the inverted 
A, the T, the V, the L, the i_j, and the H. In order 
to hold the flaps in a proper position during their 
dissection, the forceps or the fingers of the operator will be required, the 
latter being always more satisfactory when the flaps which are being raised 
are massive. 
Hemorrhage.-Hemorrhage may often be prevented by an assistant making 
pressure with his finger on the main trunk of an artery, the branches of 
which come within the sphere of operation. In this way, by compressing 
the facial arteries where they pass over the inferior maxillary bone, in front 
of the masseter muscles, plastic operations on the face, or those for hare-lip, 
may be executed in an almost bloodless manner. In all instances where an 
artery or a large vein is wounded without being entirely severed, the vessel 
should be cut completely across, and subsequently tied. 
Punctures arc made with the sharp-pointed bistoury, with a thumb lancet, 
or with needles. In using eithei' the bistoury or the lancet for this purpose, 
the instrument is held in the first position, with the point at nearly a right 
angle with the surface to be divided. If it is desired to regulate very nicely 
the depth of penetration, the fingers can grasp the blade of the lancet or the 
bistoury at the required distance from the extremity, and thus prevent the 
instrument from going to a greater depth than that desired. The opening 
of an abscess, or the operation of venesection, will afford good examples of 
this plan of dividing the soft parts. 
When the puncture is made with a long, delicate needle, it constitutes 
acupuncture. The instruments required for its execution are long, very 
slender, and properly-tempered needles, which can be fitted into a handle, 
Fig. 1117. 
Fig. 1118. 
Acupuncture needle and handle. 
the latter being detached as soon as the puncture is completed (Fig. 1118). 
This operation, quite common among certain Asiatics, as the Chinese and VENESECTION. 
265 
Japanese, is frequently employed in this country, and in certain chronic 
affections of the nerves, as sciatica, is sometimes productive of much good. 
The needles often require a 
little rotatory motion to in- 
sure their ready entrance 
into the tissues. 
With a view to establish 
temporary counter-irritation 
in chronic cases of disease, 
an instrument capable of 
making numerous shallow 
punctures, in a manner al- 
most painless, is sometimes 
employed. (Fig-1119.) In 
using it the needles are drawn some distance into the hollow metallic shell 
by means of a stem and spring, and then released, when they are driven in 
an instant a short distance into the skin. The counter-irritation can be 
much increased by dipping the points of the needles, before using them, into 
a mixture consisting of equal parts of croton oil and olive oil. The punctures 
are followed, in the course of twenty-four hours, by numerous vesicles. 
Fig.1119. 
Instrument for making multipunctures. 
The operation of venesection requires an accurate anatomical knowledge. 
During the sanguinary period in the history of the profession it was no un- 
common thing for the blacksmith of a neighborhood to act as phlebotomist. 
Consequently aneurismal varix and varicose aneurism were not unfrequently 
encountered as a result of the ignorance of the operators, who did not under- 
stand the relations of the brachial artery at the bend of the arm. Phlebitis, 
lymphangitis, and neuralgia were also induced,-the first two by the con- 
tusion or laceration of the vein or lymphatics from dull instruments, or per- 
haps by the use of foul lancets; and the last, by the -wounding of branches of 
the internal cutaneous nerve. From these accidents 
many persons lost the use of their arms, and not a 
few perished. 
Blood may be abstracted from any of the super- 
ficial veins; but the bend of the arm, or the inner 
side of the leg, above the ankle, is the region gen- 
erally selected for the operation. 
Superficial Surgical Anatomy at the Bend of 
the Arm.-The veins on the anterior and the pos- 
terior part of the radial side of the forearm, a short 
distance below the elbow, join to form a single 
trunk,-the radial vein,-which constitutes one of 
the chief tributaries of the cephalic. The venous 
branches on the two aspects of the ulnar side of the 
forearm, by their confluence, form one of the prin- 
cipal roots of the basilic vein ; whilst the median 
vein, occupying the middle of the forearm, divides 
into two trunks, the one passing upward and outward 
to join the cephalic,-the median cephalic,-and the 
other upward and inward to enter the basilic,-the 
median basilic vein. Underneath the last-named 
vessel lies the brachial artery, only separated from 
it by the aponeurosis-bicipital-derived from the 
tendon of the biceps muscle. Over the surface 
of the same vein pass numerous nerve-filaments, 
branches of the internal cutaneous. (Fig. 1120.) The median basilic vein, 
which is usually the largest and most prominent, would naturally be selected 
Venesection. 
Fig. 1120. 
Arrangement of veins at the bend 
of the arm. 266 
VENESECTION. 
for the abstraction of blood ; and yet, as it lies over the brachial artery 
and is covered by several nerve-twigs, it is certainly the most dangerous 
location for the operation. For this reason the median cephalic is to be 
preferred, especially by persons who are not very familiar with the use of 
the lancet. 
The saphena interna vein* is formed by branches arising over the inner 
surface of the dorsum of the foot and of the ankle; the vessel is accompanied 
by the long saphenous nerve, which usually lies along the posterior face of 
the vein. 
Instruments.-Two instruments are employed for the purpose of opening 
a vein in the operation under consideration, viz., the thumb lancet (Fig. 1121) 
and the spring lancet (Fig. 1122). The latter is to be preferred, not only on 
Fig. 1121. 
Fig. 1122. 
Thumb lancet. 
Spring lancet. 
account of requiring less skill in its use, but from the painless manner in 
which the vein can be divided by it. 
In the hands of a skillful operator, however, provided the blade be sharp, 
it is a matter of very little importance which instrument is employed. 
Operation at the Bend of the Arm.-The arm should be carried off 
at a right angle with the body, the hand at the same time grasping a broom- 
stick or a cane. A strip of roller bandage or a ribbon, one inch wide, is next 
carried twice around the arm, about three inches above the elbow, and se- 
cured by a bow-knot. This fillet must be made sufficiently tight to arrest 
the circulation through the superficial veins and cause them to swell up, and 
yet not so tight as to interrupt the circulation through the brachial artery. 
The veins, should they not be made sufficiently prominent by the simple 
constriction of the arm by the band, may be rendered more so by the patient's 
alternately tightening and relaxing his hold upon the cane, while the operator 
rubs the forearm for a few moments from below upward. The same move- 
ments will promote the flow of blood after the vein has been opened. 
The surgeon now locates the position of the brachial or any other artery 
which may be present. If using the thumb lancet, he grasps the blade of 
the instrument between the thumb and the index finger, and, while the vein is 
fixed by a finger of the other hand, placed below the seat of operation, a 
puncture and incision is made into the vessel in a direction oblique to its lon- 
gitudinal axis. If the division of the vein and that of the integument accu- 
rately correspond, and are sufficiently free, a stream of blood will issue with 
considerable force, and should be received into a vessel provided for that pur- 
pose. When the spring lancet is used, the fleam must also be placed obliquely 
over the vein, and pressed somewhat against the skin before being sprung, 
otherwise it will fail to enter the vessel. 
The advantage of the oblique incision is twofold. It produces a gaping 
orifice favoring the flow of blood, and, in the event of the instrument's coming 
in contact with a nerve-filament,-a very likely occurrence,-the branch will VENESECTION. 
267 
be severed completely across, causing less inconvenience or evil consequence 
than would result from a simple puncture. 
Should the patient become pale and sick at the stomach, with indistinct 
vision, and should profuse perspiration appear on the forehead and face, 
the flow must be stopped. These symptoms may occur either from the 
erect position occupied by the patient, or from a mental impression, even 
before two ounces of blood have been abstracted ; and, when such is the 
case, the recumbent posture must be assumed, with the head low. 
When the requisite amount of blood has been drawn, the fillet should be 
untied and removed from the arm, and a finger or the thumb placed upon the 
vein immediately below the wound, in order to prevent any oozing while the 
surface is being wiped clean with a napkin. The opening is next closed by 
placing over it a compress of old linen, and securing the same with the fillet 
used to compress the arm, applied in the form of the figure-of-eight. The 
wound usually heals in two or three days, when the dressing may be thrown 
aside. 
Venesection on the Leg.-When it is desired to abstract blood from the 
leg, the surgeon selects one of the chief branches of the internal saphena, 
on the inner aspect of the leg, about four inches above the ankle. A bandage 
is first placed around the junction of the middle and the lower third of the 
leg, in order to interrupt the return of the blood through the surface veins 
of the extremity, after which the foot may be placed in a vessel of warm 
water, the latter serving to increase the fullness of the veins, by inviting a 
greater flow to the part. When this is done, the opening is made by either 
the thumb or spring lancet, in the same manner as that practiced at the bend 
of the arm; and the closure of the wound is also effected in the same way. 
When, after venesection, the parts around the wound become inflamed, 
tender, and swollen, the affected surface should be covered with a lotion of 
lead-water and laudanum, the arm kept in a slightly-flexed position, and rest 
rigidly enforced. CHAPTER XV. 
GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS. 
The preparation of a patient to undergo an operation is the first duty 
of the surgeon. Indifference on this point, except in cases of pressing emer- 
gency, argues great rashness and disregard of human life on the part of 
an operator. jSTo operation, however simple, is entirely devoid of danger. 
I have seen a patient perish from the introduction of a sound into the blad- 
der; and there are numerous similar cases recorded. Death occasionally 
follows the removal of a sebaceous cyst from the scalp, or the amputation of 
a finger, operations generally deemed of the most trivial nature. 
The first question which a surgeon should decide when called to consider 
a case of surgical disease supposed to demand operative interference, is the 
one of necessity. In general, it may be said that no operation is proper when 
the cure can be accomplished in any other way. If the disease is one which 
does not threaten either the comfort, the usefulness, or the life of the indi- 
vidual, the performance of any operation had best be declined. We are never 
justifiable in subjecting patients to unnecessary risks. Even in instances 
where, under ordinary circumstances, an operation would be proper, if, on a 
careful examination, the chances prove to be largely against recovery, the 
knife should be withheld. Again, when the probabilities are that an operation 
will not leave the patient in a better condition than before its execution, it 
will be wise to abstain from any interference. 
No operation should be undertaken against the judgment of the surgeon 
on account of the importunity of the patient. Responsibility cannot be 
divided or transferred. A patient who is to be subjected to a grave opera- 
tion is entitled to have a reasonable assurance from his surgeon that a suc- 
cessful issue may be anticipated. Of course it is not designed to convey the 
impression that the surgeon is expected to guarantee the lives of his patients. 
Many things which no human foresight could have prevented may occur to 
cause a case to miscarry. All that is claimed is that an operation should 
only be undertaken under conditions which usually insure success. To reach 
such knowledge it is necessary to inquire into the habits of a patient. Per- 
sons who lead indolent lives, or are addicted to the excessive use of alcoholic 
drinks, or to the indulgences of the table, are bad subjects for the knife. 
They cannot endure the shock of a surgical operation, and are often, after 
such, attacked by delirium tremens. Their wounds'tend to suppuration, or 
to erysipelatous inflammation, and consequently either slough or heal very 
slowly. 
Age.-Neither the very young nor the very old tolerate well severe opera- 
tions. Children cannot safely endure any great loss of blood ; and the same 
is true of aged persons. In the former class, it is desirable to postpone 
operations of any magnitude as long as possible, or as long as may be con- 
sistent with the health of the patient; and in those far advanced in years, 
where the disease will not, from its nature, tend to shorten life, or where the 
use of the knife will not prevent the reproduction of the disease, it is well to 
abstain from any operation. Amputations and lithotomy are rarely success- 
ful in persons who are over seventy-five years of age. 
Pregnancy contra-indicates the use of the knife, save in cases where, from 
the nature of the affection, delay of surgical interference jeopardizes the life 
of the patient. 
268 GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS. 
269 
Menstruation is a condition likewise unfavorable to operations. The system 
is usually more or less perturbed during its presence, and the morale of the 
patient also impaired. The most desirable period to operate in females during 
the period of life in which this function is present is four or five days after 
its subsidence, or ten or twelve days antecedent to its appearance. 
Internal organs.-A careful inquiry should be instituted into the condition 
of the internal organs before consenting to undertake any severe operation. 
Under this head, the state of the renal organs occupies a most conspicuous 
position. Nothing is so essential to the success of a surgical operation as 
sound kidneys. Should these organs be diseased, the risks attending the use 
of the knife are increased a hundredfold. 
Organic disease of the liver is also a bar to operations, though in a much 
less degree than structural alteration of the kidneys. Disease of the lungs 
is also unfavorable to the success of an operation, especially one in which 
the work of repair is likely to be tardy. Not only is pulmonary tuberculosis 
inimical to the reconstruction of wounds, but its own destructive processes 
are intensified by the additional demand made upon the resources of the 
general system after an operation. 
The condition of the heart must not be overlooked in making the surgical 
inventory of the organs. A fatty state of this organ, with or without valvu- 
lar complications, tells against the success of a severe operation. And this 
should always be suspected when a patient's circulation or respiration 
becomes disturbed aftei- a little active exertion. Persons so affected do not 
react well, and may perish from collapse. Slight valvular disease, though 
an unfavorable lesion, is not a bar to operations of necessity. 
Idiosyncrasies and peculiarities of constitution form also proper subjects for 
inquiry. There are some persons who find that even a scratch on their 
persons will obstinately refuse to heal for a long time, some in whom the 
slightest wounds will provoke an attack of erysipelas, and others again who 
possess a peculiarity of the vascular system making it difficult to control the 
flow of blood which follows a wound. I remember a number of cases in 
which indifference to this condition came very near causing the loss of life. 
In one instance the patient actually perished before the surgeon's eyes, 
although the operation was a very trifling one, viz., the excision of a cyst 
the size of a hickory-nut, which was situated on the side of the thorax. 
Women possessing a very excitable nervous system, with hysterical tend- 
encies, are not favorable subjects for an operation, especially one of severity; 
and, when added to this organization there exists a feeble heart, the dangers 
are greatly increased. Such persons are incapable of withstanding the effects 
of shock, and often sink under the consequent exhaustion. Mere nervous 
excitement, if not associated with despondency, does not contra-indicate an 
operation. Persons of such a temperament, though they suffer much, both 
in body and in mind, soon recover their usual flow of spirits, which, acting- 
like a cordial, serves to hasten recovery. 
Obesity is highly unfavorable to the success of a surgical operation. The 
wounds of persons loaded with fat suppurate freely, heal slowly, and are 
often attacked with erysipelas, and sometimes with sloughing. 
Residence.-Persons living in the country generally endure operations 
better than residents of large towns oi- populous cities. The explanation of 
this fact must be sought for in the more simple and less artificial mode of 
living among country people. 
Inflamed state of parts, and constitutional infection.-To operate on a part 
in a state of acute inflammation is a most dangerous procedure. A prudent 
surgeon would not even amputate a tonsil which was actively inflamed, or 
ligate a mass of hemorrhoids in a similar condition. To excise a joint in a 
state of acute inflammation would be homicide. The presence of any acci- 
dental indisposition is a bar to operations. The occurrence of a severe head- 
ache, or a chill, a little febrile excitement, or an inflamed gum in a child, 
are all sufficient reasons for withholding the knife. 270 
GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS. 
In cases of malignant disease, where the diathesis is strongly marked, or 
where there are at the same time morbid growths of this nature in different 
organs or parts of the body, operations, save those of necessity, e.g., tying 
a bleeding artery, are inadmissible. The same is true when the system is 
suffering from pyaemia or erysipelas. 
Chronic disease, in many instances, enhances the probability of success of 
a surgical operation. Thus, we find that articulations which have long been 
the seat of caries or necrosis admit of being excised with singular impunity. 
The system is tolerant of the knife from having become adjusted to the 
local irritation. The tendency, however, of protracted suppuration to work 
structural alteration in the kidneys and the lungs should always induce the 
surgeon to examine into the condition of these before deciding on the course 
of treatment. 
Epidemic influences.-During the prevalence of epidemic diseases, such as 
erysipelas or diphtheria, operations should be declined, except those which 
do not admit of delay. Inattention to this precaution has often been followed 
by loss of life, the wounds becoming attacked by the prevailing disease. 
Mental states.-Patients will occasionally become exceedingly despondent 
just before the period fixed for an operation, under a conviction that the re- 
sult will be fatal. If, aftei' a reasonable assurance, the mind cannot be dis- 
abused of this impression, the operation may be postponed. Such a state of 
mind not only operates against the patient's recovery, but also exercises a 
very depressing effect on the surgeon. 
Profound grief, anger, fear, or great mental excitement are all unfavorable 
to the work of repair, whether existing at the time of or after the employment 
of the knife. 
The deportment of a surgeon will do much to allay fear and inspire hope- 
fulness in the heart of a patient. lie should never underrate or overrate the 
dangers of an operation, but should be frank and honest in all his represen- 
tations. Nothing is more contemptible, not to say wicked, than for a surgeon 
to treat the apprehensions or anxieties of patients with ridicule or levity. 
Preliminary training.-It is frequently necessary, in order to secure the 
success of an operation, that some form of apparatus shall be worn. Many 
persons are so intolerant of restraint that they fret themselves into a state 
of nervous excitement whenever they are obliged to maintain an unusual 
posture. It is always well, in anticipation of such constitutional peculiarities, 
where an apparatus has to be worn, to have the instrument applied for a few 
hours at a time, and for two or three days before the operation is executed, 
that the person may become adjusted to the new position. 
There is a class of operations designated by Mr. Paget 11 decorative," by the 
French " operations de complaisance,"-i.e., operations which arc solicited from 
motives which relate to personal appearance or convenience: an opaque or 
collapsed eyeball must be removed in order that an artificial eye may be ad- 
justed; a mole on the face, surmounted by a tuft of hair, becomes obnoxious 
and must be excised; a contracted finger will not admit of a glove, and 
must be got rid of; or the spermatic veins become slightly dilated, and nothing 
short of ligation will satisfy the mind of the patient. What is the duty 
of the surgeon in the premises? Many persons, either as a result of educa- 
tion or organization, arc supersensitive in regard to any personal imperfec- 
tion. There are men who would face a cannon with more courage than a 
varicocele, and there are women who would endure martyrdom rather than 
a mole on the face. It is, generally, useless to reason with such persons 
about the harmless nature of these infirmities, and there is no way to restore 
either their peace of mind or usefulness except by surgical skill. And that 
skill should not be withheld when there is a reasonable prospect of giving 
relief. I can recall some very curious experiences in this kind of surgery. 
Having now briefly discussed the most important subjects connected with 
the undertaking of operations, I shall next consider some matters connected 
with their execution. GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS. 
271 
Apartments-Ventilation and Temperature.-When possible, the room 
occupied by a patient about to undergo an important surgical operation should 
be largo, well ventilated, and so situated as to command an abundance of 
sunlight. An open fireplace will always insure, in winter at least, the best 
interchange of air. The evils attending an insufficient amount of pure air 
are not properly appreciated. Much of the mortality of hospitals is to be 
attributed to this source of danger. The presence of a number of open and 
suppurating wounds is well calculated, by the putrescent emanations 'which 
they emit, to deteriorate the atmosphere of a ward or building; and hence 
arises the peril of overcrowding such places. Every patient, whether in or 
out of a hospital, should have not less than sixteen hundred or two thousand 
cubic feet of air, and this should be changed every twenty-five or thirty 
minutes, both day and night. The steam-fan in hospitals, and the open fire- 
place in all places, are the only perfect means of ventilation. The latter 
answers well during cold weather, when it is necessary to keep up a good fire, 
but is inferior to the fan, which, being in constant operation, is as effectual 
during the night, when the windows are closed, as in the daytime, when they 
are frequently open. In private houses the windows can be slightly opened 
above and below, so as to insure a proper atmospheric circulation, but no 
draught of air must be allowed to blow on or over the patient. Persons who 
have undergone severe surgical operations are peculiarly sensitive to alter- 
nations of temperature. In winter time the heat of the room should not be 
suffered to fall below 68° F. or to rise above 75°. Attention must be paid 
to rest, diet, and medication. One or more days of quiet both of body and 
mind, the proper regulation of food, which must be determined both as to 
quality and quantity by the peculiarities in each case, and the removal of 
all sources of intestinal irritation by a gentle cathartic, are subjects which 
demand special attention. 
Patients who are robust, of a full habit, and with a strong, active circula- 
tion, should be put for a few days, when this is possible, upon a spare diet, 
chiefly farinaceous iq its character. In other instances it may be necessary 
to administer tonics, stimulants, and anodynes, in conjunction -with concen- 
trated nourishment for some time, in order to enrich those constitutional re- 
sources which are to insure success after the operation. 
Assistants.-In most operations it is necessary to have one or more as- 
sistants. The number will be specified in connection with special cases. When 
possible, the assistants should be persons familiar with the duties pertaining 
to the tasks to be assigned them in the operation ; or, if not, they must be in- 
structed by the surgeon, and the part assigned to each must be clearly desig- 
nated before the operation is commenced, so that every want and contingency 
shall be anticipated, and no interruption or confusion occur. 
The practice of making surgical operations a spectacle, by introducing a 
considerable number of medical men merely for the purpose of witnessing 
the performance, is reprehensible. It is calculated to disturb the composure 
of the persons to be subjected to the knife, and to give publicity to their dis- 
eases, which few are willing to allow. 
The Time for the Performance of an Operation.-The middle of the 
day, or that period between eleven and one o'clock, is the time best adapted 
for an operation, not only on account of the light, but also because, in case 
any subsequent bleeding should occur, the surgeon may have daylight to 
aid him in his search for the source of the hemorrhage and the application 
of his ligatures,-a work very inconvenient and troublesome when done by 
artificial light. 
It is probably best not to specify to the patient the particular hour when 
the operation is to be performed. He is too apt to look forward to its ap- 
proach with feelings akin to those of a criminal contemplating the hour 
appointed for his execution. 
Preparations for an Operation.-Before commencing an operation every- 
thing necessary for its execution should be provided and in its proper place, 272 
GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS. 
even to a sponge, or a thread, or a needle. Not only must this provision 
embrace the ordinary instruments and appliances required for the case 
in hand, but also those which under extraordinary circumstances may be 
needed. A surgeon exhibits his wisdom and foresight by anticipating all 
possible contingencies that can arise, and thus guarding and forearming 
himself against any surprise. 
Not the least important agents which belong to the operating-table are 
restoratives, as ammonia, brandy, or whisky. In difficult and protracted 
operations the presence of an electro-galvanic battery will not be out of place, 
in the event of the respiration failing. 
The instruments to be employed by the surgeon should be thoroughly 
cleansed beforehand, and subjected to a bath of carbolic acid before being 
used a second time. 
The same scrupulous cautions should be observed on the part of the oper- 
ator' with regard to his own personal cleanliness, such as carefully washing 
his hands before commencing the operation, especially if he was previously 
engaged in dressing a wound, A surgeon who may be attending a case of 
erysipelas or of diphtheria is thereby rendered unfit to perform, or to assist 
in or be present at, any important operation, without first taking a bath and 
making an entire change of clothing. 
Every patient should have his own sponges, and these must never be used 
a second time, unless they have been thoroughly disinfected in a carbolic acid 
bath. They should be allowed to remain in this bath during the interim of 
dressings. 
In using the sponge, it should be first fully dipped in water and then 
squeezed thoroughly dry before placing it upon the wound, against which it 
should be firmly pressed-not wiped-and quickly withdrawn, so that the 
operator may not be delayed in making his incisions; or, if ligating, that he 
may distinctly perceive the point from which the blood issues. 
The peculiar reticulated structure of the sponge (so well adapting it to 
catch and retain foreign matters), and the general carelessness in the use of 
this article, induce me to believe that little loss would be experienced if it 
were entirely-discarded from use in surgical operations. I frequently employ 
as a substitute small pledgets of soft oakum, or, what is better, a plain, soft 
towel. 
The table.-Most operations can be performed, with the greatest conveni- 
ence, upon a firm, narrow table, which should be covered with folded comfort- 
ables or blankets. 
All preparations should be made in an adjoining room, in order that they 
may not bo witnessed by the patient. 
As a rule, the etherization should be conducted while the patient is yet in 
bed, and in the presence of none save the surgeon and the assistant whose 
duty it is to administer the anaesthetic. When the anaesthetic has taken 
effect, the table may be introduced and the patient placed upon it. This 
done, the hair, if present, must be cleanly shaved from the parts involved in 
the operation. 
The position occupied by the surgeon during an operation must necessarily 
vary according to its nature; it should, however, always be that which will 
enable him to perform his work with the greatest facility. 
Before commencing an operation, the surgeon should have a clear and 
distinct plan of its details, as far as it is possible to form one. It is true 
that the most maturely arranged scheme may require material modification 
before the work is completed. But that fact does not lessen the necessity 
or the value of a preliminary plan. And, after the operation has once been 
commenced, the operator's undivided attention should be concentrated on the 
work in hand. 
It should be executed expeditiously and deliberately, but without hurry 
or indecision. "And now with God's help," was the expression used by an 
old master in our art when about to begin an operation; and it were well if GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS. 
273 
every surgeon, impressed with the solemnity of the moment, could honestly 
adopt the same language. 
Anatomical demonstrations, or light, trifling conversation, are sadly out of 
place when a fellow-being is under the knife. 
It is generally supposed that familiarity with blood renders the surgeon 
hard, pitiless, and insensible to suffering. There can be no greater mistake. 
It is true he may exhibit no emotion, and may give no vent to his feelings, 
either in words or in expression, yet within the few minutes of an operation 
are often compressed more intense sensations than are experienced by many 
persons during a whole lifetime. 
Hemorrhage,-It is important, in all operations, that as little blood as pos- 
sible should be lost by the patient. Wardrop regarded the loss of blood as 
useful rather than harmful, and directed that a patient should be bled to 
fainting before commencing an operation,-a doctrine so monstrous as justly 
to tarnish his name to no small degree. The prevention of hemorrhage does 
not, however, imply that a surgeon must stop and tie every vessel which is 
divided as he proceeds. Many branches will, after a few jets, contract and 
cease to bleed. Others, which do not, may be temporarily controlled by the 
fingers of an assistant or by serres-fines. In this manner a mammary gland 
can be excised, or a fatty tumor removed, without any delay on the part of 
an operator. When, however, the divided vessel is one of any magnitude, 
when the patient is feeble and unable to endure the loss of blood, or when 
the operation is likely to be prolonged, it will be best to ligate every bleeding 
vessel as the surgeon proceeds. 
When it is desirable to complete an operation before attending to the per- 
manent control of the hemorrhage, a soft towel can be thrust into the wound 
and retained by pressure, as a tampon, and will be quite sufficient to arrest 
the bleeding at the time. The vessels can be tied by raising the towel a small 
part at a time and securing each artery as it bleeds. 
When a patient during the progress of a tedious operation, cither from loss 
of blood or from nervous exhaustion, grows pale and faint, and the respiration 
becomes feeble, the head should be immediately lowered to a level with the 
body, or even below the latter. If this change of posture is not sufficient to 
restore measurably the color to the face and lips and to improve the breathing, 
a more energetic respiration must be excited through the reflex action of 
the fifth pair of nerves. For this purpose the vapor of ammonia should be 
applied to the nose, and the face slapped with a towel wet with cold water, 
or water should be dashed over the surface. 
If the surface of the body becomes cold and the symptoms of exhaustion 
continue to increase, brandy may be given by the mouth or thrown into the 
rectum, the circulation at the same time being invited to the surface by the 
application of external warmth. Heated bricks or bottles of hot water rolled 
in flannel constitute the best means of applying artificial heat: they should 
be laid along the spine, between the limbs, and against the soles of the feet. 
Dry friction of the extremities with the hand is also a powerful means of 
imparting heat and inviting the blood back into the capillary vessels. 
The free and general oozing of blood from the surface of a wound, which 
frequently delays the dressing, is often very promptly arrested by wetting a 
napkin in some hot water, squeezing out the redundant fluid, and placing it 
against the bleeding surface, retaining it for a minute in contact with the 
parts. After its removal the surface will present a blanched appearance. 
The propel- temperature of the water is best determined by placing the nap- 
kin or towel, after being dipped in the hot water, against the side of the face 
or forehead, and if not too hot to be borne by the assistant it is ready for use. 
Dressing.-After an operation is completed and all bleeding has ceased, 
the wound should be dressed as soon as possible, that is, as soon as the sur- 
geon has a reasonable assurance that no vessels have been overlooked which 
will be likely to bleed when the patient has recovered from the shock of the 
knife. While I am never in a hurry to close up a wound, I am not favorable 
VOL. II.-18 274 
GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS. 
to that practice which allows the parts to remain open for a considerable 
length of time, or until the surface has become entirely glazed with a fibrin- 
ous film. There may, of course, be exceptions to this rule, as in deep and 
extensive wounds situated in important surgical regions. Ten or fifteen 
minutes are generally required to wash away the blood from the surrounding 
parts; and if, after this is done and the skin is well dried, no arteries are seen 
to bleed, the dressing may be commenced. 
Before closing wounds of considerable magnitude, a drainage-tube should 
always be introduced, in order that any oozing blood or redundant serum 
may be promptly conducted away, and thereby the risks of suppuration be 
diminished. 
The material employed for the purpose of drainage should be of a quality 
calculated to produce as little irritation as possible. Those in common use 
are rubber tubes of different sizes, with some holes cut out along the sides, 
fine oakum twisted into a cord, catgut, and horse-hair. Before the introduc- 
tion of any of these materials they should be treated with a solution of 
carbolic acid (acid 1 part and water 30 parts). When oakum is used and 
both ends are out of the wound, a fresh wisp can be introduced by fastening 
it to one extremity of the old one. As the latter is withdrawn the former 
will take its place. 
Horse-hair can be inserted into a wound by placing the middle of a number 
of hairs in the notch of a probe and pressing them to the bottom of the 
wound. On the withdrawal of the probe the hairs remain. 
The ordinary dressings required after the approximation has been effected 
are a piece of dry lint, or of lint moistened with water ox* with carbolated 
oil, laid upon the surface of the wound, and a thick compress, which, in turn, 
may be covered with a layer of oakum, and the whole firmly bound upon 
the parts with a roller bandage. 
The patient is now ready to be transferred to the bed. After this the part 
operated upon must be placed in such a position and secured in such a man- 
ner as to insure the utmost quiet. There is nothing which proves so preju- 
dicial to the healing of a wound as motion. 
If the antiseptic plan is adopted, it will be necessary that the carbolic 
acid spray be continued throughout the entire operation, and also during the 
closing of the wound, and that the dressings be such as have been already 
described under the head of what is known as the Lister method. 
After-Treatment.-There is a very great difference in the degree of pain 
experienced by patients after operations similar in kind. If there is only a 
little smarting, it will usually wear away in a short time, and requires no 
very special attention. If, however, the pain is severe, or the patient is 
nervous and restless, an anodyne is demanded, and may be given by the 
mouth oi' the rectum, or introduced subcutaneously, and repeated as often 
as is necessary to give relief and to restore tranquillity. 
Pain is a powerful depressant and is universally dreaded, and there is a 
vast difference in the capacity of different persons to endure acute suffering. 
Sir Astley Cooper relates the case of a brewer's servant, a strong, robust 
man, who bad been suffering several days from a thecal abscess, the result of 
a splinter which had run under the nail of the affected finger, and who, on 
the incision being made to evacuate the matter, fell back and immediately 
expired. Hunter saw a man die immediately after the loss of a testicle, ap- 
parently from the agony which he suffered. Before the discovery of anaes- 
thetics doubtless many persons perished from the pain incident to tedious 
operations. 
Diet.-A patient who has passed through the ordeal of a severe and pro- 
longed operation, either with or without the loss of much blood, even though 
unconscious of the whole procedure, from having been under an anaesthetic, 
has nevertheless sustained a severe shock, the effects of which extend through- 
out the economy. How shall this evil be remedied? Some think the orderly 
operations of the different organs are best restored by an abundance of food GENERAL CONSIDERATIONS fylTH REGARD TO OPERATIONS. 
275 
and stimulants. This must be accepted with considerable limitations. When 
there has been great loss of blood, the propriety of replenishing the emptied 
vessels by the free use of liquid nourishment admits of no doubt, and nothing 
fulfills the requirements of the case more perfectly than milk, to which may 
be occasionally added a little brandy or whisky. A little strong coffee admin- 
istered from time to time forms a valuable adjuvant to our list of restoratives 
when there is an absence of that nerve-energy so necessary to establish 
reaction. 
Next in importance after milk rank animal broths. These may be used 
after the lapse of four or five days, or when the surgical fever begins to de- 
cline. Eggs also constitute a most valuable article of nourishment, and are 
particularly indicated as soon as the stomach has recovered a reasonable de- 
gree of tone. While it is true that the patient needs a liberal supply of food 
to repair the waste incident to traumatic disturbance, it is no less true that 
in case of much shock being present, and until the harmonious action of the 
organs has been recovered, he may be greatly damaged by overfeeding. The 
course to pursue is not to press nourishment beyond the power of the patient 
to appropriate it. Rest is better than food, under such circumstances. When- 
ever a sense of nausea, of gastric distention, or of disgust is produced by 
food, it is best not to insist on its use, except in very small quantities and 
at short intervals, and when the stomach is very irritable rectal alimentation 
is to be preferred. The previous habits of a patient must in a great measure 
determine the treatment to be pursued after an operation. If the patient 
is addicted to the excessive use of liquor, stimulants cannot be safely with- 
drawn, and must be allowed to a reasonable extent. This is equally true with 
respect to opium-eaters: they cannot be deprived of the drug without serious 
detriment. 
Medication.-The use of anodynes, as has been already stated, is important 
in all instances where the patient suffers pain or is restless after an operation. 
The quantity to be given of course depends on circumstances. As a rule, a 
full dose at once is better than a small dose often repeated; that is, where the 
symptoms are urgent. Tonics also, when the patient requires support, must 
be given, such as quinine, compound tincture of cinchona, and, in anaemic 
conditions, tincture of chloride of iron. As long, however, as a patient is doing 
well, drugs are an impertinence. 
Removal of Dressings.-These, as a rule, are not to be disturbed earlier 
than the third day after the operation. If found to be unsoiled by the dis- 
charges from the wound, and the latter appears to be doing well, they may 
be allowed to remain for one or two days longer. There are other cases in 
which, in consequence of the leakage from the wound, the dressings become 
saturated and offensive, causing considerable local irritation: in such in- 
stances they should be removed and renewed without respect to time. 
A vessel should always be at hand for the reception of the soiled dressings 
when removed; and, to destroy all unpleasant emanations, they may be 
sprinkled with a solution of permanganate of potash, of nitrate of potash, 
or of girondin, and immediately taken out of the room. The same course 
as to disinfection and removal from the chamber of the patient should be 
observed with regard to the alvine evacuations. It is only by the prompt 
removal of every soiled article from the apartment that the atmosphere can 
be preserved in a condition fit for the respiration or safe to the life of a 
surgical patient. 
While these injunctions affecting the articles of dressings are to be enforced 
with scrupulous care, the clothing of the patient and his bed-linen demand 
equal attention. These must be changed every two or three days, taking 
pains to have those which are to take their place well dried and warm before 
they are used. 
In hospitals the wagon of Morton will bo found exceedingly useful, as it 
contains, in a very compact form, everything that is necessary for the recep- 
tion of soiled dressings and the renewal of fresh ones, and can readily be wheeled 276 
GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS. 
from bed to bed. Fig. 1123 represents a modification of this wagon by Dr. 
Hart, used in the hospital of the University of Pennsylvania. 
Fig. 1123. 
Morton's hospital wagon. 
Many persons, after operations, complain of great soreness of the limbs, 
also of pain and stiffness in the back. When the change of bed and of personal 
clothing is made, nothing will so much contribute to the relief, comfort, and 
refreshment of the patient as to have the body well rubbed with alcohol. 
Friction of the limbs, made by the hand, will often exercise a good influence 
in calming nervous restlessness and inducing sleep. When pain or distress 
over the lumbar spine is severe, a mustard-plaster applied for twenty-five 
minutes over this region will frequently give relief. 
Accidents during and after Operations. 
Exhaustion.-Notwithstanding every possible precaution, an operation 
may be so prolonged, on account of the attachments and relations of a growth, 
that a large amount of blood will be lost, in consequence of which a dan- 
gerous exhaustion will ensue. Or the latter condition may occur without 
hemorrhage, as a result of shock or failure of the necessary nerve-force. This 
may follow a double amputation, the extirpation of a large and deeply-seated 
tumor in the neck, or a complicated case of lithotomy. Many persons, doubt- 
less, before the discovery of anesthetics, perished from the depressing effects 
of pain. It must, however, be remembered that although the employment 
of anesthetic agents may prevent all consciousness of suffering, they do not 
exempt the organs of the body from shock; and on this account it is very 
necessary, even though no expression of pain may escape the patient while 
under the influence of ether or chloroform, that the operation be executed 
with as little delay as possible. 
When the exhaustion is the consequence of the loss of blood, the dangers 
which environ the future of the case are greatly enhanced, even though the ACCIDENTS DURING AND AFTER OPERATIONS. 
277 
patient should rally from its immediate effects. The system thus reduced is 
peculiarly liable to pysemic infection, erysipelas, gangrene, and various forms 
of low inflammations. 
The exhaustion following an operation is generally indicated by a death- 
like pallor of the face, a feeble pulse and feeble respiration, sighing, indis- 
tinctness of vision, an upward rolling of the eyes, noises in the ears, coldness 
of the limbs, excessive restlessness, and often by vomiting. 
To meet such an urgency, it is necessary, first, that the /unctfion of the 
brain shall be maintained. The patient must, therefore, be placed in the re- 
cumbent position, with the head low, and, in extreme cases, with the lower 
extremities and the body raised so as to determine the blood to the head. 
Bottles of hot water rolled in pieces of flannel should be applied between and 
along the sides of the limbs, and to the spine. A sinapism may be laid over 
the epigastrium, and dry friction addressed to the extremities. Brandy 
or whisky should also be given by the mouth, or, when deglutition is im- 
possible, by the rectum. These stimulants can often be given in milk or in 
strong coffee. 
Anodynes are of the greatest importance in such cases, and may be intro- 
duced into the system by the mouth, by the rectum, or subcutaneously. In 
the employment of both stimulants and anodynes the surgeon must be very 
discreet. Neither should be given in large quantities or be too frequently 
repeated. Absorption, in the condition of the system under consideration, 
may be temporarily suspended; and hence these agents may accumulate, 
and after a time, when reaction has begun to set in, they may induce, in 
the first case, a dangerous excitement, or, in the case of anodynes, a fatal 
depression. 
When the exhaustion is the result of excessive hemorrhage, the transfusion 
of blood may be adopted with some prospect of benefiting the patient. 
Patients do sometimes die while under the knife. Death under such cir- 
cumstances may be due to exhaustion, to the effects of an anaesthetic, or to 
some concealed organic disease which had escaped detection. Such an event, 
however induced, must be looked upon as a great calamity. God grant it 
may never be a part of my personal experience! 
Hemorrhage may follow shortly after the closure of a wound. WThen this 
is the case, it is generally attributable either to some vessel having been over- 
looked, or to the closing of the parts before reaction has been sufficiently 
restored to test the security of the vessels. It is always an unfortunate cir- 
cumstance to be compelled to reopen a wound once closed. Even if done 
only a few hours after its adjustment, it complicates the subsequent process 
of repair. For this reason the part should be elevated when it is possible 
to do so, cold applied, and pressure made with a bandage. These measures 
failing to arrest the flow, the wound must be opened and the source of bleeding 
sought for and controlled: there is no alternative. 
Entrance of Air into a Vein.-This is a dangerous occurrence. It will 
be best prevented by encircling the vessel, when its division becomes neces- 
sary, wdth a ligature, both above and below the point where it is to be severed. 
Should this accident occur during an operation on the neck, the head of 
the patient should be immediately lowered, and stimulants administered by 
the rectum, at the same time keeping up artificial respiration. (See vol. i. 
p. 517.) 
Embolism.-After operations in which much blood has been lost, there is 
always more or less tendency to the formation of coagula. This may take 
place in the vessels of the extremities, and, by forming an obstruction to the 
circulation, cause the limb to fall into a state of gangrene. From the same 
tendency to coagulation of the blood a clot may form in the heart sufficiently 
large to destroy life. I have seen both these accidents occur. It is of the 
first importance that patients thus predisposed should be kept perfectly quiet 
and in the recumbent posture. 
Any considerable effort, such as sitting up in bed, when the power of the 278 
GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS. 
heart has been much lessened and the vessels deprived of a large amount of 
blood by an operation, exposes the individual either to a fatal syncope, or to 
the formation of obstructive plugs of fibrin. 
Alarming symptoms sometimes follow the use of anaesthetics, which will be 
considered under the head of anaesthesia. 
There are accidents which follow operations and which materially add to 
the mortality of surgical cases. They are as follows: 
Secondary Hemorrhage.-This is generally occasioned by sloughing, or by 
a diseased state of the artery. The period of its occurrence is rarely earlier 
than the seventh day or later than the twentieth day after the operation. 
There are, however, exceptions to this rule. In view of such a contingency, 
the surgeon should never fail to be prepared for the emergency. When there 
is any reason to apprehend this accident, as where the wound assumes an 
unhealthy appearance, or where the vessels were found to be in an atheroma- 
tous condition at the time of their ligation, the surgeon should give de- 
tailed directions to the nurse or other assistants how to act should the 
necessity arise ; be should instruct them in the management of the tourniquet, 
previously placed loosely over the principal vessel of the limb, or, if this is 
not feasible, in the preparation of a graduated compress, to be thrust for- 
cibly into the opening from whence the blood issues, and there held firmly by 
the fingers until the presence of a medical attendant can be obtained. The 
subsequent course to be pursued must depend on the peculiarities of the 
individual case. Sometimes it may be necessary to ligate the vessel in the 
wound, at other times the artery above. Occasionally, the removal of the 
limb may offer the only chance of recovery. 
Mania a Potu.-In persons of notoriously intemperate habits an injury or 
an operation will invite an attack of alcoholic mania or delirium tremens. 
Treatment.-Opium, bromide of potassium, and chloral are the remedies which 
are found most efficient in controlling the nervous symptoms. One grain of 
opium, or its equivalent, twenty-five drops of laudanum, may be given every 
two or three hours until sleep is induced. Twenty grains of bromide of 
potassium, with fifteen grains of chloral hydrate, dissolved in some mint-water 
with a little syrup, and given every two hours, will often secure a quiet sleep. 
Morphia may be given hypodermically when there is much irritability of the 
stomach. One-fourth of a grain may be deposited in this way (under the 
skin) and repeated once every three hours until the narcotic effect is realized. 
In cases attended with violent tremors, the addition of some antispasmodic 
to the anodyne, such as the ammoniated elixir of valerian or the tincture 
of hops, will be found to have a very happy effect in calming the excitement. 
It is possible, however, to carry the opium treatment to an injurious extent, 
in over-anxiety to bring the patient quickly under its influence, by increasing 
the dose of the drug too rapidly, or by exhibiting it too frequently. 
When the conjunctiva becomes injected, with a turgid face and throbbing 
temporal arteries, a blister to the back of the neck will be found useful. In 
persons who are feeble and broken in health from intemperance it is better 
not wholly to withdraw the accustomed stimulus, but to allow a little whisky 
or other alcoholic drink from time to time. It is also highly important that 
nutritious liquids be administered during the attack, not only as a means of 
sustenance, but also with a view to diminish that insatiate thirst and craving 
for drink which pursues the unfortunate victim like an unrelenting demon. 
Hysteroidal Delirium.-There is anotherform of delirium which partakes 
of the nature of hysteria, and seems to depend on a loss of the moral inhibi- 
tive power, occasioned by shock. It may be either of a quiet or of a boisterous 
kind. The first is most common in persons of advanced life who have under- 
gone operations; the second in adults. 
The passive delirium manifests itself by hallucinations and rambling con- 
versation and restlessness. The patient conceives himself to be in a strange 
room, is constantly asking to be taken home, imagining strange persons about 
the bed and strange faces on the wall, and frequently endeavors to unloose ACCIDENTS DURING AND AFTER OPERATIONS. 
279 
or tear off the dressings. I have in two or three instances seen these mental 
delusions harass patients for some time after the operation for cataract. 
The boisterous variety is often a sudden intrusion, and is more common in 
females than in males. The patient laughs or cries, sings, prays or exhorts, 
at one time is harassed with muscular tremors, and at other times with violent 
contortions of the body. These eccentric exhibitions are injurious to the 
patient by interrupting that mental and physical quietude which is so 
important after operations. 
In the quiet form of traumatic delirium there is evidently some cerebral 
anaemia present, which is most satisfactorily removed by stimulants, together 
with opiates and antispasmodics. In the violent form, the bromides with the 
antispasmodics are the proper remedies. 
Tetanus is not a common sequel of operations. When it has occurred in my 
hospital experience, I have had every reason to believe that it was to be referred 
more to the effects of the injury which necessitated the use of the knife than 
to the operation itself. The infrequency of the disease in temperate climates 
may bo illustrated by the fact that during thirty-two years at Guy's Hos- 
pital the number of cases of tetanus did not exceed one case in 1575 patients. 
In the Pennsylvania Hospital the disease, as a result of operations, is almost 
unknown. In tropical countries, however, the prevalence of the disease is 
very great, children being especially disposed to such attacks. The mortality 
in India and tropical America from this cause has been particularly noticed 
by writers. 
The remedies to be employed in tetanus are cathartics, followed by the use 
of opium, bromide of potassium, and chloral hydrate. Nourishment and 
stimulants are also of the first importance, as a means of sustaining the 
system, in the hope that the disease may exhaust itself. 
When the jaws are locked and food cannot be introduced into the mouth, 
it may be conducted into the pharynx and oesophagus through the nasal 
passages, by means of a flexible tube. 
If there is reason to believe that a nerve has been pricked, or included in 
a ligature, it should be laid bare and divided across. 
Retention of Urine, though not in itself a dangerous occurrence after an 
operation, is a very common one: hence the condition of the bladder should 
be inquired into at each visit, and the catheter employed whenever the 
patient is unable to empty the viscus. 
Muscular Spasms occasionally follow an operation, involving certain groups 
of muscles, or affecting those of an entire extremity. 
A change of position, a firmer application of the roller, or a subcutaneous 
injection of morphia will generally afford the necessary relief. 
From what has been said it will be obvious that the success of an operation 
depends upon many contingencies. Patients will die, and no amount of skill 
or human foresight can prevent it. It is the will of Providence that this 
should be so; and, if the surgeon is conscious of having fulfilled his whole 
duty in the premises, without an error of omission or of commission, he can 
reverently and submissively bow to the Almighty fiat, with a conscience void 
of offense towards God and man. CHAPTER XVI. 
ANAESTHETICS. 
Nothing is more dreaded than pain. All nations, from the most savage 
to the most civilized, have their pain-destroying remedies. To render a sur- 
gical operation a painless procedure has been a dominant thought in the 
minds of physicians from the remotest times, as will appear by reference to 
the early records of the art. For this purpose the Greeks, Romans, and 
Arabians employed the volatile principles of narcotic plants, such as the 
mandragora, stramonium, hyoscyamus, and others of a like class. The 
method of employing these agents was not unlike that now in use in admin- 
istering our well-known anaesthetics. Theodoric is represented as directing 
the inhalation of vapor from a sponge previously saturated with a decoc- 
tion of various narcotic substances. At St. George's Hospital, London, John 
Hunter put into execution the suggestion of Mr. Moore for the prevention 
of pain in surgical operations, by making powerful pressure over the chief 
nerves of a limb by means of a tourniquet. The limb was amputated while 
thus constricted, and, it is said, with only a trifling degree of suffering. 
Among the Chinese, and still later with the Mohammedans, the Indian 
hemp was used for the same object. In more recent times, the experiments of 
Sir Humphry Davy with nitrous oxide gas, first published in 1800, appear to 
have opened a new field in this kind of inquiry. This agent was found to 
have the property, when taken into the respiratory organs, of destroying 
pain. The interest attracted to the subject, however, after a short time sub- 
sided, and, like the germs of many other discoveries, it passed for a time into 
oblivion. 
Wardrop, of London, recommended the copious abstraction of blood pre- 
vious to an operation, with a view to lessen sensibility. I have seen the 
carotid artery tied in a person who had lost a large amount of blood from a 
wound in the neck without any manifestation or sign of pain on the part of 
the patient. But the adoption of such a degree of depletion for the object 
contemplated is too hazardous to be entertained for a moment by any sen- 
sible person. Before the introduction of our present anajsthetics, it was the 
custom of most surgeons to administer to their patients, previous to the 
operation, a large dose of opium or of some of its preparations. The effect 
of this was to diminish both the severity of the pain attending the use of 
the knife and the mental excitement incident to the performance of the 
operation. 
In 1844 a dentist of Hartford, Connecticut, Dr. Horace Wells, revived Sir 
Humphry Davy's discovery, by inhaling in his own person the nitrous oxide 
gas, and, while in an insensible state, having a tooth extracted without the 
least consciousness of pain. Similar operations, and with a like result, were 
performed by Dr. Wells on a number of patients to whom he administered 
this gas. Notwithstanding the signal success which seems to have then 
attended the use of this agent, it again fell into discredit, in consequence of 
the indifferent success attending some experiments before the faculty and 
students of Harvard University. 
In 1846, Dr. Morton, who was a student of Dr. Wells's, was led to try the 
effect of inhaling the vapor of sulphuric ether as a means of destroying sen- 
sibility. His first experiments were made upon himself, and afterwards on 
others, his patients. After a number of trials he succeeded in establishing to his 
280 ANAESTHETICS. 
281 
own satisfaction both the safety and the certainty of ether as a pain-destroying 
agent. Like his master, Dr. Wells, he was next to subject the matter to a 
public trial. The conflicting emotions which stirred his nature may well be 
imagined. If the experiment proved successful, his name would be rendered 
immortal; if he should fail, only ridicule awaited him. The exhibition was 
given at the Massachusetts General Hospital, on a patient from whose neck 
Dr. John C. Warren was about to remove a tumor. The ether was admin- 
istered, and the operation performed while the man lay unconscious of the 
whole procedure. A second experiment was made on a patient of Hay- 
ward's, with a similar result. Such were the circumstances attending the 
discovery and introduction of anaesthesia. Who can measure the impor- 
tance of this signal event to the human race! It remained for America to 
confer this great boon on suffering humanity. How many monuments have 
been raised to perpetuate the names and commemorate the prowess of martial 
heroes who have stained the earth with the blood of slaughtered men and 
have sent a wail of woe over entire continents! But where is the pillar or 
modest column meeting the eye of native-born or foreigner to tell the tale 
of two humble dentists whom God enabled to invent a sleep that antidotes 
every pain ? Ungrateful nation! the names of Wells and Morton will never 
be forgotten, though no memorial stone or enduring shaft shall rise at thy 
bidding. 
In Philadelphia, Dr. Peace is said to have performed the first operation 
under ether (a reduction of a dislocated shoulder) upon a patient in the 
Pennsylvania Plospital. The public excitement attending the discovery of 
the anaesthetic properties of ether spread rapidly on both sides of the At- 
lantic. In England, the first operation under ether (an amputation of the 
thigh) was done at the University College Hospital, by Liston, December 
22, 1846, and the year following, 1847, Sir James Simpson, of Edinburgh, 
discovered chloroform. 
The advantages resulting from the use of anaesthetics are incalculable. 
The certainty of being able to pass through an operation without experi- 
encing any pain relieves the mind of that dreadful anxiety and alarm which 
would otherwise disturb the nervous system of a patient. Fear and pain are 
both powerful depressants. And it is quite apparent that the inordinate 
development of nervous excitability, incident to the social life of our people, 
renders the exhibition of anaesthetics more imperative at the present time 
than it would have been when men and women were cast in a rougher mould 
and were trained under less artificial modes of living. 
The moral shock attending an operation is also greatly lessened. What a 
painful and embarrassing trial would it be to a refined and sensitive woman 
to be compelled, with a full consciousness of all that was taking place, to 
undergo any of those tedious operations for the relief of diseases peculiar to 
her sex, and in which some personal exposure is unavoidable! The use of 
anaesthetics is exceedingly important, not only in preventing suffering while 
examinations are being made, but in enabling the practitioner to reach a correct 
diagnosis, by suspending sensibility and those voluntary movements which 
ordinarily so vitiate and complicate the investigation of surgical cases. Again, 
anaesthetics, by securing the passivity of the patient and allowing the most 
deliberate and precise use of the knife, contribute to both the safety and the 
completeness of operations executed in dangerous regions. Cutting opera- 
tions performed without the use of an anaesthetic not only inflict pain at 
the time of their execution, but are followed by severe burning pain for a 
long time afterwards, requiring often large and repeated anodyne doses be- 
fore relief can be obtained. A patient, however, who is rendered insensible 
previous to the use of the knife recovers sensibility slowly, and consequently 
the severity of the pain is in a great measure past before the effects of the 
anaesthetic disappear, thus making the administration of opiates unnecessary, 
except to a moderate extent. 
JZtzs the use of anaesthetics lessened mortality in surgical operations F is a ques- 282 
ANESTHETICS. 
tion which has been frequently asked. Sir James Simpson, after a somewhat 
extended investigation of this subject, came to the conclusion that the death- 
rate was diminished by their employment. Dr. Arnott, on the other hand, 
reached a different conclusion, affirming that the mortality has been increased. 
Bryant has analyzed 2586 capital operations performed prior to, and 1847 
executed since, the introduction of anaesthetics, showing that the results as 
to mortality are about the same. The records of the Pennsylvania Hospital 
exhibit a greater death-rate since than before the use of these agents. It 
must, however, be borne in mind that the introduction of massive machinery 
into our manufacturing establishments and the multiplication of railroads 
have materially changed the character of the injuries for which operations 
are required at present. 
Precautions in the Use of Anaesthetics, 
First. The article used should be perfectly pure. All mixtures of these 
agents are improper. Should an accident occur, it would be impossible to 
know upon which ingredient of the mixture to lay the blame. 
Second. The anaesthetic which experience has proven to be the safest should 
be selected. The surgeon is bound by the highest moral considerations to do 
this, and his patient has a right to expect that it will be done. 
Third. The administration should be the office of one assistant, and of one, 
too, who is entirely familiar with his duty. And his attention should never 
be diverted from the work on hand as long as the continuance of the influ- 
ence of the anaesthetic is required. It is an immense relief to the mind of a 
surgeon to feel that his attention can be concentrated wholly upon the oper- 
ation, and that he can perform it without the distraction of having to watch 
the inhalation. 
Fourth. A third person should always be present during the administration 
of an anaesthetic, especially when the agent is administered to females. This 
precaution is absolutely necessary in order to preserve the character of the 
practitioner, as the patient may have the sexual appetite so excited under 
the stimulus of the anaesthetic as to imagine herself to have been the help- 
less victim of personal violation. Charges of this nature have been made 
by females in several instances, in all of which there is good reason to believe 
the charges were entirely unfounded, the offense imputed existing only in the 
imagination of the patient. 
Fifth. It is highly proper that the anaesthetic be administered to the patient 
while in the recumbent position (especially when chloroform is employed), 
and that a free access of atmospheric air be allowed. 
In the use of ether this is not so imperatively necessary. 
In operations on the mouth and jaws the semi-recumbent attitude may be 
adopted. 
Sixth. No solid food should be allowed for four or five hours before the 
exhibition of an anaesthetic. The apprehension usually entertained by the 
patient before an operation almost always suspends digestion ; and a loaded 
stomach is most certainly followed by vomiting, both during and after the 
action of the anaesthetic. The presence of solid food also favors cerebral 
congestion, and interferes with free respiration by encroaching upon the 
cavity of the thorax. 
Seventh. It is necessary also to have the clothing about the neck and body 
entirely loose. If artificial teeth are worn, they should be removed before- 
hand. Neglect of this last precaution may be followed by serious conse- 
quences, from the plate becoming displaced and dropping into the pharynx. 
Eighth. As conversation is calculated to disturb that mental quietude so 
necessary to the rapid production of anaesthesia, it is desirable that no con- 
versation be indulged in by the surgeon, or by those about the patient, at 
least until the loss of consciousness begins. 
Ninth. In cases where the patients are much exhausted, the administration PRECAUTIONS IN THE USE OF ANAESTHETICS. 
283 
of half an ounce or an ounce of good whisky or brandy, before the anaesthetic 
is given, will be of great value. 
Tenth. When the anaesthetic is administered at night, requiring the use of 
artificial light, it must not be forgotten that the vapor of ether will descend, 
and on this account the candle, lamp, or gaslight should be held above, not 
beneath, the inhaler. Chloroform is not inflammable, and hence does not 
require the same caution in the use of artificial light as does ether. 
Eleventh. In cases of anchylosis of the lower jaw, and when an operation 
is contemplated, it is not safe to give an anaesthetic unless the stomach is 
quite free from food. I have seen a person, from inattention to this point, 
wellnigh perish, by reason of the surgeon's inability to get anything into the 
mouth to clear out the pharynx, which bad become obstructed by materials 
rejected by the stomach while under ether. 
Supposed Contra-indications to the Use of Anaesthetics.-There are 
very few conditions in which an operation is necessary under which anaes- 
thetics cannot be given with safety, particularly sulphuric ether. It has been 
thought that in valvular disease of the heart, or in fatty degeneration of that 
organ, the use of anaesthetics is contra-indicated ; but in my experience I have 
not found this to be the case. The physiological effect of ether is to impart 
tone to the heart, and to increase the vigor of its action. 
Chloroform being a depressant to the central organ of the circulation, its 
administration in cases of structural alteration, either in the valves or in the 
walls of the heart, is not unattended with danger. 
In cerebral congestion or inflammation, or where intense headache exists, 
it is best to withhold the exhibition of either sulphuric ether or chloroform. 
The depression attending shock does not contra-indicate the use of an an- 
esthetic, though here, as in heart disease, ether is to be preferred to chloro- 
form, and for the same reason, viz., that it does not diminish the power of 
the circulation, but rather increases it. Without an anesthetic, the use of 
the knife before a patient reacts is calculated to intensify the shock, as pain 
in itself is a serious depressant. 
In cases of bronchitis, the use of anesthetics, especially ether, is generally 
followed by an aggravation of the cough ; but this is not sufficiently impor- 
tant to preclude their use. The same is true of tubercular disease of the 
lung. 
Persons who suffer from epilepsy are not thereby disqualified for the use 
of anaesthetics. Even should the latter excite a paroxysm of the disease, no 
evil effects remain. I have seen such attacks take place while trephining a 
patient for epilepsy; they were apparently excited by the etherization. 
Ether may be given with impunity to persons suffering with renal disease. 
In cases of children suffering from croup, when there is extreme exhaus- 
tion, coupled with great mechanical obstruction to the entrance of air, and 
the operation of tracheotomy is demanded, the anaesthetic must be with- 
drawn after the incision is made through the integument. 
In all cases where patients are greatly enfeebled, a very small amount of 
ether or chloroform will produce the characteristic effects. This fact must 
not be overlooked when, under such a condition, it becomes necessary to 
anaesthetize a patient. 
Anaesthetics may be divided into general and local. 
General Anaesthetics. 
A considerable number of chemical compounds are known to possess anaes- 
thetic properties; but those ordinarily employed in practice are sulphuric 
ether, chloroform, nitrous oxide, a mixture of chloroform and ether, the bi- 
chloride of methylene, and ethidene. 
Ether.-Sulphuric ether, to be pure and suitable for the purpose of inhala- 
tion, should have a specific gravity of 0.720. 284 
ANESTHETICS. 
Phenomena attending administration.-1. The first of the effects attending 
the administration of sulphuric ether is an undue irritation of the lining 
membrane of the respiratory passages, causing a slight cough and a sense 
of suffocation, generally of short duration and soon followed by a factitious 
state of insensibility. Dr. Flagg and Dr. Packard, of this city, have called 
attention to this condition, as one of which advantage may be taken for open- 
ing abscesses and for performing other operations requiring only a moment 
for their execution. 
2. This state is soon followed by another, in which the nervous system 
participates. The symptoms are usually those of pleasurable excitement, 
manifested by laughter, extravagant expressions or exclamations, accom- 
panied or followed by more or less muscular and facial contortion, and often 
by violent struggles. The behavior of a person is much influenced by natural 
mental and moral peculiarities. The dominant proclivities usually crop out 
as the intoxication begins. The sedate and sober-minded rarely make any 
extravagant demonstrations, while those of a jovial or rollicking disposition 
are usually boisterous. During this stage of excitement the pulse quickens, 
the pupils contract and dilate, the respiration is conducted sometimes quietly, 
almost inaudibly, and at other times in a full, noisy manner. The limbs are 
frequently rigid, or may be agitated by tremors. Often at this period the 
surface of the face, neck, and breast becomes blotched with patches of erythema, 
attributable, doubtless, to some excitation of the cutaneous nerves. 
3. Next follows the stage of relaxation and insensibility. The limbs begin 
to lose their rigidity, becoming relaxed and limp, so that the arm or the leg, 
if raised, drops helpless upon the withdrawal of the support. The respiration 
becomes long, slow, regular, and attended with snoring; the urine occasion- 
ally escapes from the bladder; the pulse, at first frequent, now becomes 
slower and fuller, and the pharyngeal glands are stimulated to unusual activity, 
causing a large accumulation of a tenacious, mucous secretion in the fauces 
and throat. Not unfrequently a purple, livid, or leaden color appears on the 
face and lips. The parts which seem to lose their sensibility last arc the con- 
junctiva and the genital organs. 
Time.-The time required for producing complete anaesthesia by ether 
varies very much in different individuals, some requiring not more than from 
six to eight minutes, while others are affected only after twenty or twenty- 
five minutes. The average time I find to be about fifteen minutes, the amount 
of ether consumed varying from four to five ounces. 
Recovery.-The manner in which recovery takes place from the anaesthesia 
of ether or chloroform differs in different cases. In some instances, patients 
will awake quietly out of sleep, at first a little confused or bewildered, but 
soon able to collect their thoughts in an orderly manner, and to speak in- 
telligently, though having not the least idea of time, and exhibiting great 
surprise or incredulity when told that the operation or examination is over, 
requiring again and again to be assured of the fact. Others, unless roused 
by a shake or addressed in a loud voice, will continue quietly to sleep for half 
an hour or longer after the withdrawal of the anaesthetic; while in other 
cases recovery is characterized by wild, incoherent, or ludicrous talk, by ex- 
travagant expressions of gratitude, and often by hysterical sobbing. 
Modes of Administration.-Various mechanical.contrivances have been 
devised from time to time for administering ether. Among these may be 
mentioned the inhalers of Lente, of Allis (Fig. 1124), of Goodwille, of Clover, 
and others. 
That of Dr. Allis consists of a wire or a metal frame, over which a roller 
bandage is stretched by recurrent turns, and the whole inclosed either by a 
metal or by a patent-leather cylinder, fashioned at one end so as to fit over the 
face. The ether is poured over the layers of muslin which are stretched 
across the apparatus from side to side, and which necessarily expose a large 
surface for the escape of the vapor. Dr. Albert Smith bisects a large gum 
ball and lines the half to be used with canton flannel. I do not, however, ETHER. 
285 
believe that we possess a more simple or satisfactory appliance for the 
administration of ether than that of a simple cone formed out of a large 
table-napkin or a medium-sized towel. (Fig. 1125.) I never employ any 
Fig. 1124. 
Fig. 1125. 
Dr. Allis's inhaler. 
Cone formed out of a towel for inhaling ether. 
other contrivance. It may not be the most economical, but it is very much 
the most convenient, and is always attainable. 
The early effects of the anaesthetic, such as the irritation of the respiratory 
passages and the sense of suffocation usually experienced, should be explained 
to the patient before its administration, and he should be assured that these 
sensations are temporary, will soon pass away, and need cause him no alarm. 
Instruction should also be given him as to the manner of taking the anaes- 
thetic, that is, by moderately forced or deep inspirations and expirations. 
As the action of ether is sometimes irritating to the skin when brought in 
contact with it, it is well to smear a little cold cream or sweet oil over the 
exposed parts of the face before the inhalation begins. After sprinkling two 
or three drachms of ether over the inner surface of the cone, the latter should 
be placed over the mouth and nose, leaving space sufficient between the two 
for the free admission of atmospheric air. This plan is much to be preferred 
to that in which the inhaler is held close down upon the face, which must 
necessarily not only cause great irritation of the respiratory organs, but 
also produce a sense of terror and provoke resistance in the patient. As the 
inhalation progresses, in a little time the air-passages become less sensitive, 
and the ether-napkin may be allowed to rest upon the face. Every two or 
three minutes the cone must be replenished with the anaesthetic. Sometimes 
the breathing is carried on in a silent and quiet manner, and it becomes 
necessary to rouse the consciousness of the patient by pressing the thorax, 
by shaking the body, or by a command sufficient to let him understand the 
necessity for a more vigorous respiration. 
Should the patient in the early stage of intoxication manifest much ex- 
citement, a gentle, assuring word, with or without the passage of the hand 
softly over the forehead, will generally restore quiet and confidence. Except 
when the individual persists in attempting to seize the hands of the admin- 
istrator, or to put away the inhaler, it is better not to hold the arms or the 
legs, as the very feeling of restraint will only provoke resistance. When 
given in the gradual manner, the full effect of the anaesthetic can be obtained 
without creating any serious struggle ; and whenever the long, snoring respi- 
rations begin, the insensibility may be considered complete. 
Cautions during the Administration.-The collection of tenacious mucus, 
which frequently forms in the pharynx during the exhibition of ether, should 
be cleared away from time to time. This can be most conveniently done by 
the finger covered with a linen cambric handkerchief. 286 
ANESTHETICS. 
If the face becomes cyanotic from venous congestion, the anesthetic should 
be immediately removed until the proper color is restored. A long inspiration 
usually induces this change very promptly. 
Vomiting may occur both during and after the administration of the an- 
esthetic. In the first instance it is usually announced by short, convulsive 
movements of the muscles of the abdomen. These signs do not, however, 
necessarily require the removal of the ether. On the contrary, by continu- 
ing the anesthetic the vomiting can often be prevented. When such is not 
the case, the ether must be immediately suspended, and not re-applied until 
the stomach is unloaded. 
Occasionally the vomiting is preceded by a marked pallor of the face, a 
cold, moist skin, with a feeble respiration and a slow pulse, after which the 
matters are suddenly ejected from the stomach. When these symptoms ap- 
pear, the ether must be removed until vomiting is over, and care taken to 
clear the throat of whatever particles of food may not have been discharged. 
Should breathing become short and stertorous, and the lace purple, it will 
become necessary to withdraw the anaesthetic at once. If the respiration 
is not quickly re-established, the tongue should be seized and drawn out 
of the mouth by the forceps or a tenaculum. This must be done in order to 
open the glottis and thus allow the air to pass into the lungs. The breathing 
may be excited by slapping the face, neck, and breast with a towel dipped in 
cold water. If these precautions are not sufficient to remove and avert 
the asphyxia which is now impending, resort must be immediately had to 
artificial respiration, by the Marshall Hall or the Sylvester method. It is in 
such emergencies that the electro-galvanic battery can be used with great 
advantage, by passing the current along the phrenic nerves and over the wall 
of the thorax. If the threatening symptoms do not disappear, brandy or 
whisky should be thrown under the skin or into the rectum. 
After-Effects.-The most common sequels of ether inhalation are nausea 
and vomiting, headache, and sometimes an irritating cough. In females 
nervous symptoms of a hysterical nature are frequently witnessed. 
In relieving the nausea and vomiting it is scarcely necessary to prescribe 
any remedies : half an hour or an hour will usually suffice for these to wear 
away. If, on the contrary, they are persistent, nothing will more satisfactorily 
secure relief than a hypodermic injection of morphia. One drop of dilute 
hydrocyanic acid or five drops of chloroform in a little mint-water will also 
be found to act well. Salicylic acid in doses of six or eight grains, dissolved 
in a solution of citrate of ammonia and given at intervals of half an hour, 
often has an excellent effect. Effervescent draughts, lime-water, etc., I have 
never seen productive of much good. The headache usually requires a night's 
rest for its removal; but some relief will be afforded by administering aromatic 
spirit of ammonia in camphor-water. Ice-water applied to the head will 
usually aid in alleviating the pain. 
The cough is generally due to nothing more than bronchial irritation, 
which will subside in an hour or in less time. When this doesnot occur, and 
the cough continues for several consecutive hours, it is probably owing to 
the presence of pulmonary congestion, which in turn may end in pneumonia. 
Such terminations may be encountered in old persons with feeble hearts. 
Counter-irritation by mustard-plasters should be applied over the chest, and, 
to quiet the cough and equalize the circulation, a mixture containing car- 
bonate of ammonia, morphia, and tincture of digitalis should be given. Wine- 
whey or other stimulants should also be used. 
Hysterical exhibitions are best mastered by a hypodermic injection of 
morphia, or, if this cannot be conveniently administered, by bromide of 
potassium, either with or without elixir of valerian. 
Chloroform.-Chloroform is perfectly limpid, colorless, and non-inflammable. 
Its tendency to deteriorate by exposure to light, especially when it is of a 
certain density, suggests the propriety of keeping this agent in a dark place. CHLOROFORM. 
287 
The physiological action of chloroform on the nerve-centres varies at dif- 
ferent stages of its administration. At the early period, or that of excitation, 
the vessels of the brain become greatly congested; but as the insensibility 
progresses, the vascular fullness is exchanged for a state of diminished ten- 
sion, so marked, indeed, that the encephalon becomes paler than in the normal 
condition. With this appearance of cerebral anaemia, consciousness, sensa- 
tion, and voluntary movements begin to fail, though reflex motility may for 
a short time become more active in the voluntary muscles. Although the 
medulla spinalis is slightly affected almost simultaneously with the brain, yet 
as the anaesthesia progresses its effects upon the spinal cord become more 
and more prominent, so that the reflex excitability of the muscles of animal 
life is suspended and the limbs lie utterly relaxed and powerless. Notwith- 
standing this complete paralysis of the voluntary muscles, the heart and those 
muscles which carry on the work of respiration continue to perform their 
functions. 
It is said that sensation and voluntary movements may be destroyed and 
yet consciousness remain,-a fact which would seem to indicate that chloro- 
form may affect the spinal cord independently of the brain. I have never seen 
this condition. That the sensibility may be benumbed and the patient at the 
same time be conscious, so that slight pain is not experienced to a degree 
sufficient to excite muscular movements, is unquestionably true. But, if a 
suture be introduced during the continuance of this condition, it will be found 
that the puncture of the needle is followed by unmistakable manifestations 
of pain. 
Of the manner in which chloroform suspends sensation we know very 
little. Bernard supposed this to be effected by a temporary coagulation of 
the contents of the nerve cells, and that the gradual return of sensation was 
from the restoration of the neurine to its original state. This explanation, 
with others which might be mentioned, is purely hypothetical and requires 
no further notice. 
The effect of chloroform is that of a depressant, acting, through the gan- 
glionic system, directly upon the heart, and causing a notable diminution in 
the force of the latter. 
Modes of Administration.-Various appliances are used for administering 
chloroform. It is sometimes poured over a sponge inclosed in a cone formed 
out of a towel. But the simplest and perhaps the safest plan is to use a small 
cone made out of a napkin or linen cambric handkerchief, sprinkling a small 
quantity of the anaesthetic, not exceeding half a drachm, from time to time 
over the inner surface of the cone, allowing ample space between the latter 
and the face for the free admission of atmospheric air. The attention of the 
administrator should never for a moment be withdrawn from his work. The 
pulse, the respiration, and the color of the face are the three important things 
to be closely observed. 
Chloroform should never be administered to a patient except in the recum- 
bent position. The chest and neck must be free from all constriction. 
The amount of chloroform required to produce full amesthesia will vary in 
different persons. Those who are in the habit of indulging freely in alco- 
holic drinks or in opiates will require considerably more than those who ab- 
stain from such excesses. From two drachms to half an ounce is the quantity 
usually demanded. The time necessary for the amesthetic to take full effect 
ranges from four to seven minutes. 
Phenomena attending administration.-A short time after the inhalation is 
commenced, some slight excitement occurs, manifested by rambling ejacula- 
tions, rigidity, and muscular struggles. These are generally of short duration. 
The pulse, at first a little hurried, soon becomes slower and weaker; the 
breathing is deep and sometimes noisy; the vessels of the face and of the 
ocular conjunctiva are seen to be congested; the eyes are suffused with tears, 
and in a short time the patient passes into a state of insensibility and uncon- 
sciousness. 288 
ANESTHETICS. 
Recovery from the state of insensibility is in most respects like that fol- 
lowing the use of ether, except that in the latter the intoxication is more 
protracted and more liable to be followed by vomiting. 
Symptoms frequently occur during the administration of chloroform of a 
character which will demand immediate attention. These may proceed, it is 
said, from three different sources, viz., the brain, the lungs, and the heart. 
I am disposed to think that the heart is primarily involved in most cases 
in which alarming symptoms appear, and that the brain and lungs suffer 
secondarily. These symptoms may be slight, or they may be severe and sud- 
den. When arising from what is regarded as cerebro-spinal poisoning, the 
breathing becomes stertorous and the countenance blue. In most instances 
the removal of the anaesthetic and the free admission of air will suffice for 
the patient's relief. Should this be otherwise, the danger to life is imminent: 
both the respiration and the circulation may suddenly cease, and the indi- 
vidual perish. 
When the evil effects of chloroform are concentrated on the medulla, the 
breathing either stops abruptly or is performed in a shallow, gasping manner; 
the face becomes livid; the pulse is scarcely perceptible; the pupils are widely 
dilated, and death follows from asphyxia. When death ensues from syncope, 
the action of the anaesthetic is expended on the cardiac ganglia. The heart 
ceases to beat; a death-like pallor overspreads the face, and the respira- 
tion, which may continue in gasps for a short time after the circulation stops, 
is soon arrested. In many instances these fatal cases can be referred to a 
fatty condition of the heart, or to carelessness in the exhibition of the chloro- 
form, in not observing the first signals of danger, or in a too rigid exclusion 
of air. Yet in other cases the fatal result is so sudden, and takes place so 
early in the inhalation, that no explanation is possible, either on the ground 
of structural alteration in the internal organs, or on that of recklessness on 
the part of the administrator. It would appear that death may occasionally 
occur from irritability of the stomach, the poisonous effects being mani- 
fested by persistent vomiting, most probably due to the action of the anses- 
thetic on those ganglionic masses of neurine related to the pneumogastric 
nerves. 
The treatment necessary to meet these poisonous effects of chloroform 
must be prompt. The anaesthetic must be immediately withdrawn, and the 
head lowered below the plane of the body, even suspending the patient, if 
necessary, by the heels. The tongue must be strongly dragged forward out 
of the mouth by a tenaculum, in order to admit air into the larynx; and, 
with a view to stimulate the respiratory function, ammonia may be held to 
the nose. Air must be freely admitted into the apartment by raising the 
windows or by opening the doors. The surface of the face and thorax must 
also be flagellated with a wet towel, or dashed with water, thus acting on 
the cutaneous nerves of the parts, which are all exciters of the respiratory 
movements of the chest. 
If these measures fail to sustain breathing, artificial respiration must be 
practiced, by compressing the walls of the thorax, or by rolling the patient 
alternately upon his side and back. A catheter may, for the same purpose, 
be conducted into the larynx, and air forced into the lungs by blowing through 
the canal of the instrument with the mouth. In the absence of any tube, 
the same object may be accomplished by pressing the larynx against the 
spine so as to close the oesophagus and direct the air into the lungs, and then 
blowing directly into the patient's mouth. 
If an electric battery is at hand, a current should be passed in the direction 
of the phrenic nerves and from the spine over the walls of the thorax. In 
addition to these measures, hypodermic injections of brandy may be em- 
ployed ; and, if the sphincter is in a condition to guard the rectum, stimulants 
may also be thrown into the bowels. 
Baillie has suggested, in cases of anaesthetic syncope or asphyxia, the 
introduction of ice into the rectum. Nitrite of amyl has been employed NITROUS OXIDE. 
289 
in three cases of chloroform-poisoning, and apparently with success.* This 
agent was dropped in some lint and held to the nostrils until the characteristic 
flushing of the face appeared, after which the pulse, "which had ceased to beat, 
again returned to the wrist. 
The injection of ammonia into the venous system has also been suggested 
by Mr. Fitzgerald, of Melbourne. 
Bichloride of Methylene.-This agent, first suggested for anaesthetic pur- 
poses by Dr. Richardson, has been used to a considerable extent in certain 
London ophthalmic hospitals, as at the Moorfields, and also at the Samaritan 
Free Hospital. In the former institution I w-itnessed its exhibition with con- 
siderable interest, the anaesthetic effect being induced in three or four minutes, 
and recovery taking place with equal rapidity. It has been used by Mr. 
Morganf eighteen hundred times in persons of different ages, some of whom 
were kept under its influence for a period of three-quarters of an hour and 
without evil effects. This agent is also strongly recommended by Mr. J. 
Spencer Wells. Several deaths by syncope, however, have occurred from 
its use, which, with the great care necessary to be observed in its employ- 
ment, have shaken the confidence of some of its early friends as to its 
value. 
Ethidene.- This agent, first used as an anaesthetic by Dr. Snow, and which 
is procured from aldehyde, gives promise of being both a safe and an efficient 
anaesthetic. It can be administered in the same manner as ether. It is yet 
too soon to speak very definitely of its claims to professional confidence. So 
far as it has been tested, it appears to possess almost the safety of ether, 
and is at the same time more agreeable to the patient, more rapid in its 
action, and followed by more speedy recovery. It is occasionally succeeded 
by vomiting, though not more frequently than chloroform. 
Nitrous Oxide.-This agent has many advantages as an anaesthetic. It is 
absolutely safe, produces its effect quickly, is followed by almost instant re- 
covery, and leaves neither nausea nor headache. Dr. Thomas, of Philadel- 
phia, has administered nitrous oxide over eighty-five thousand times without 
a single accident. Its inapplicability, however, to purposes of general sur- 
gery is quite obvious, as its effects could not be maintained with safety in a 
case requiring a protracted operation. For the extraction of teeth, the open- 
ing of abscesses, the cutting of a fistula, or in performing a tenotomy, the 
gas can be employed with entire success. 
The apparatus required for its administration consists of a large rubber bag 
or reservoir, connecting with 
a flexible tube, to which is 
attached an inhaler, the best 
being that of Dr. Thomas, of 
Philadelphia. (Fig. 1126.) 
This inhaler is constructed 
of vulcanized rubber • its 
canal is half an inch in diam- 
eter ; it has at one extremity 
an inhaling valve, and at the 
other a mouth-piece, its en- 
tire length being about eight 
inches. In the centre is fitted 
a stop-cock having a second inhaling valve. These valves should be per- 
fectly air-tight, in order that the gas can be administered without any ad- 
mixture of atmospheric air, otherwise the time required to produce anaesthesia 
is unnecessarily prolonged, and the sensations experienced during the exhibi- 
Fig. 1126. 
Thomas's inhaler. 
* British Medical Journal, August 18, 1877. 
j- Ibid., January 4, 1879. 
VOL. II.-19 290 
ANAESTHETICS. 
tion of the gas very unpleasant. Dr. Thomas objects to inhalers provided 
with hoods which cover in the mouth, except in cases of hare-lip, or where 
the jaws are stiff, rendering it impossible to pass the mouth-piece between the 
teeth. These hoods conceal the lips, which should be open to inspection, 
as the administrator is governed, in the use of the gas, very much by their 
color. 
During the administration of nitrous oxide gas the patient should be either 
recumbent or semi-recumbent. The mouth-piece is placed between the teeth 
at the end of an expiration, when the stop-cock is turned, opening a commu- 
nication between the reservoir containing the gas and the inhaler. At each 
inspiration the nitrous oxide is drawn into the lungs, and during expiration 
the air escapes through the exit valve of the stop-cock. One minute is usu- 
ally sufficient to induce anaesthesia. Should any symptoms of syncope appear, 
the tongue must be drawn forward, the head lowered, and fresh air freely 
admitted. 
Respiratory Anaesthesia.-Dr. Bonwill, a dentist, of Philadelphia, has called 
the attention of the profession to a mode of producing anaesthesia by rapid 
breathing. The plan has been tested by Dr. Hewson and others, of this city, 
but in most experiments, I believe, with a negative result. 
Comparison of Anaesthetics.-Nitrous oxide, in consequence of the asphyx- 
iated state which it induces, though perfectly safe for operations which 
can be consummated in a few seconds or minutes, and therefore particularly 
well adapted to the wants of the dentist, is quite unsuited to the purposes of 
general surgery. And ethidene being yet on trial, it is only necessary at 
present to contrast the two anaesthetics now in common use, viz., ether and 
chloroform. 
Chloroform, since it causes less irritation of the respiratory organs, is cer- 
tainly more pleasant than ether. Its anaesthetic effects are very quickly 
induced, and the patient is not quite so prone to suffer from subsequent nau- 
sea and vomiting. But, with all these advantages, it cannot be denied that 
chloroform is a much more dangerous anaesthetic than ether. It exercises 
a pernicious influence on both the respiratory and the cardiac centres, while 
ether, on the contrary, increases the power of the heart. The experiments 
of the committee appointed by the British Medical Association have very 
clearly established these points.* A number of sphygmographic observa- 
tions taken by Dr. Hand, at my request, on patients in the Pennsylvania 
Hospital, the results of which are shown in the following diagrams, establish 
very conclusively the relative influence of ether and of chloroform upon the 
heart. The pulse-tracings were taken before commencing to administer the 
anaesthetic, and during full anaesthesia, and in persons whose age and con- 
stitutional characteristics bore a general correspondence. 
ETHER. 
Normal pulse. 
Full anaesthesia. 
* British Medical Journal, January 4, 1879. LOCAL ANESTHETICS. 
291 
CHLOROFORM. 
■Normal pulse. 
l ull auasslhesiu. 
It will be seen, by following the above registrations, that the tidal and the 
percussion waves of the normal pulse in the two classes of persons who were 
the subjects of these experiments are very much alike. During the period 
of rigidity the tension of the ether-pulse was increased, while that of the 
chloroform-pulse was diminished. When full anaesthesia was reached, the 
percussion wave, and, of course, the arterial tension, representing the power 
of the heart, was greater than the normal in the patient under the influence 
of ether; while in the case of the chloroformed patient the tracings indicate 
so serious a loss of power in the central organ of the circulation that one 
might say to the patient, " As thy soul liveth, there was but one step between 
thee and death." 
But it is not necessary to adduce experiments like the above, evincing the 
greater safety of ether over chloroform as an anaesthetic. We need only fol- 
low the cases of death arising from the use of chloroform and recorded from 
time to time in the various medical journals. Up to 1869 there had been re- 
ported 210 deaths from chloroform. Dr. Baum, of this city, at my request, 
has carried the record from 1869 to 1872, collecting 195 deaths from the same 
agent, making 405 fatal results of chloroform-poisoning. During the same 
period of time not more than 6 instances of death have been imputed to the 
use of ether, and in 3 of these the anaesthetic employed was a mixture of 
chloroform and ether, a fact which should entirely exclude them from the 
computation, as the a priori inference is that the ether had nothing to do 
with the fatal result. Now, if to these 405 deaths from chloroform were 
added those which have never reached the publicity of the journals (and 
1 doubt not almost every surgeon knows of such), the number would probably 
be swelled to at least half as many more. 
It seems to me that a surgeon who, in the face of such evidence, will con- 
tinue to employ chloroform, assumes a tremendous responsibility. I hold that 
where two agents are open to choice, both capable of suspending sensibility 
and voluntary motion, we are bound, in justice to our patients, to select the 
safer. No man has any right to jeopardize unnecessarily the life of a fellow- 
being. Chloroform, except in the few cases where ether fails to produce 
decided anaesthesia, should be banished from surgical practice. 
Local Anaesthetics. 
There are a number of agents possessing the anaesthetic power when locally 
applied. Some of these destroy the sensibility by the rapid production of 
cold, and others by being absorbed and thus temporarily paralyzing the 
integumental nerves. Among the first-named class may be mentioned 
The Frigorific Mixture.-This mixture, recommended by Mr. Arnott, of 
London, consists of two parts of ice and one of salt. These materials are 
to be pulverized separately in a canvas or a linen bag, and, after being 
thoroughly mixed together by a spatula or a knife, must be surrounded by a 
piece of gauze, which, after one or two minutes, or as soon as the mixture 
begins to melt, is to be placed over the part to be anaesthetized. 292 
ANESTHETICS. 
A chilly sensation is quickly felt at the place of contact with the mixture, 
soon followed by pallor and diminished sensibility. To these symptoms suc- 
ceed a shriveled and, finally, a hard or congealed state of the skin, the part 
being destitute of feeling. Fifteen or twenty minutes will be necessary to 
induce complete anaesthesia of the part. 
The effect, however, is transient, and does not extend beyond the integu- 
ment. So that, except for opening abscesses or exposing a small cyst, it 
possesses no peculiar merits as a surgical resource. 
In operations of a very trifling nature, such as the prick of a hypodermic 
needle or the opening of a mature abscess (quite sufficient to awaken fear in 
many sensitive people), the skin may be sufficiently benumbed for the time 
by simply inclosing a lump of ice in a piece of tarlatan and holding it for a 
few moments against the surface to be punctured. 
Ether, used in the form of spray and directed upon the skin by means 
of an atomizer (Fig. 1127), was sug- 
gested by Dr. Richardson, of London, 
as a valuable local anaesthetic. The 
rapidity with which this material 
evaporates causes intense cold and 
rapid freezing of the part against 
which it is applied. Dr. Richardson, 
in one instance, excised, under ether 
spray, a scirrhous mammary gland 
from a female without any complaint 
on the part of the patient Except, 
however, in operations of a very 
transient nature, its local application 
for purposes of general surgery is very limited indeed. 
Fig. 1127. 
Hand atomizer. 
Rhigolene, one of the products from coal-oil distillation, is another agent 
used to produce local insensibility, and was proposed for this purpose by 
Professor Bigelow, of Boston, in 1846. This substance is the lightest of 
liquids, highly inflammable, boiling at 70°, and, consequently, should be kept 
in a cool place and handled with great care. Its extreme volatility and rapid 
evaporation render it peculiarly well adapted for the rapid destruction of 
sensibility in a part, the evaporation producing a temperature of 15° below 
zero. Rhigolene is used for anaesthetic purposes from a spray-bottle, in the 
same manner as ether. One or two minutes suffice for freezing the surface 
upon which it is directed. For slight operations I have been in the habit of 
using this article for several years, and with great satisfaction. 
Carbolic Acid, though at first causing irritation and pain when applied 
to the skin, soon produces a complete suspension of sensibility. If it is 
desired to benumb a part with this agent before making an incision, the acid 
may be brushed over the surface with a camel's-hair pencil. CHAPTER XVII. 
AMPUTATION. 
The term amputation, at the present time, is restricted to the operation of 
cutting off any part or the whole of a limb, and to the removal of the penis. 
The extirpation of the jaw or the mammary gland, formerly included in the 
idea of an amputation, is now more properly expressed by the term excision. 
The possibility of such a surgical operation being done, without fatally 
compromising the life of the whole body, was probably first suggested by 
what must have been often witnessed in the infancy of surgery,-the sponta- 
neous separation of a portion of a crushed or mortified limb. 
The necessity for amputation has been very much lessened in the last 
twenty years by the growing importance of conservative surgery,-a progress 
founded on a higher estimate of the natural recuperative powers of the human 
body, on improved modes of managing surgical injuries, and on the greater 
prominence given to excisions in the continuity or the contiguity of bones. 
Circumstances demanding Amputation. 
In general it may be said that amputation is proper whenever the injury 
or the disease of a part is such as to render it highly probable that with- 
out the operation the limb must be lost, or when the patient's life would 
be subjected to greater risk by the adoption of any other treatment, such as 
resection or expectancy. That persons recover occasionally from wounds of 
the most extensive and apparently hopeless character without operation is 
true; but such very exceptional cases are not to influence the judgment of the 
surgeon when deciding upon the propriety of an amputation in any given case. 
I remember an instance, in the Pennsylvania Hospital, of a patient with a 
crushed ankle, who obstinately refused to have the part removed, although 
the indications for the operation were so cleai' as to admit of no doubt what- 
ever, and yet, after a long and tedious illness, he finally recovered, with a dis- 
torted and useless foot. The result, however, was the loss of the lives of 
three other patients, who, encouraged by the obstinacy of this man, declined 
operations which, had they been performed, would in all probability have 
been successful. 
It is not simply the preservation of an injured part which should influence 
the surgeon's decision, but also the probable future condition of that part. 
A damaged finger may, by an unwise conservatism, be saved, immovably 
fixed either in a state of extreme extension or flexion; but the hand would 
have been much better and far more useful had the unfortunate digit been 
cut off. 
The conditions demanding amputation may be included under the follow- 
ing general heads: (1) injuries and diseases of the soft parts; (2) injuries and 
diseases of the bones; (3) injuries and diseases of the joints; (4) deformities; 
(5) aneurisms; (6) mortification; (7) malformations. 
Injuries and Diseases of the Soft Parts.-Under this head will come a cer- 
tain class of lacerated, contused, and gunshot wounds. When from any 
cause the soft parts are extensively torn away from the bones, leaving the 
latter uncovered for many inches in extent, when the muscles are crushed 
into a pulp, and the principal arteries and nerves severed, rendering it alto- 
gether probable that the limb will fall into a state of mortification, amputa- 
293 294 
AMPUTATION. 
tion becomes a necessity, and should be done without delay, or as soon as 
reaction has been established. 
Ulcerations.-The soft parts may be attacked by a destructive ulceration, 
the ravages of which will lay bare the bones and destroy the tissues to an 
extent which can never be repaired. Amputation, in such a case, will be 
required. 
Malignant growths.-The development of a malignant growth in the upper 
or the lower extremity, provided the signs of constitutional implication have 
not become apparent, will constitute a sufficient cause for amputation. This 
general involvement will be revealed by the enlargement of those lymphatic 
glands 'which are directly related to the tumor, by the existence of similar 
growths in other parts of the body, or by rapid emaciation, loss of strength, 
and a cachectic expression. Under these circumstances an operation would 
hasten rather than postpone the fatal event. 
When an amputation is performed for a carcinomatous disease, it should be 
done at a point some distance from the part of the limb involved • for exam- 
ple, when the malignant tumor is situated on the forearm, the knire should be 
applied above the elbow, or when on the arm, at the shoulder-joint. 
Non-malignant tumors may also, on account of the direction of their 
growth, or from pressure on the chief blood-vessels, endanger the life of a 
limb. But in such an event, and for a tumor possessing only a local signifi- 
cance, excision of the growth should be substituted for amputation of the limb. 
Injuries and Diseases of the Bones.-Under this head may be considered 
compound and comminuted fractures, caries, necroses, and tumors. 
Compound and comminuted fractures.-At one time the existence of a com- 
pound fracture, even though of a very simple nature, was sufficient to doom 
a limb to amputation. The question now, in the light of larger observation 
and experience, can only be determined by the extent of the injury, by the 
constitution and habits of the patient, and by surrounding circumstances. 
No surgeon would now for one moment contemplate the removal of a 
limb simply because of the existence of a fracture accompanied with an ex- 
ternal wound. When, however, in consequence of a railroad, manufacturing, 
or mining injury, a bone is broken in one or several places, and the soft parts 
are lacerated or crushed into a pulp, the blood-vessels and nerves also being 
torn, the knife is the only alternative. But there are circumstances in which 
a less mutilation than that depicted above may require the removal of the 
limb,-in a class of cases well known to military surgeons, in which, on ac- 
count of the absence of hospital accommodations, surgical appliances, and 
a sufficient force of medical attendants, or where it is necessary to transport 
the wounded long distances over rough roads, the prospect of recovery 
is greatly enhanced by amputation, although the same cases, under more 
favorable surroundings, or in civil practice, could be saved without the use of 
the knife. 
In like manner, the habits of a patient suffering from a serious fracture of 
the above description will influence the conduct of the surgeon. A man 
who has been addicted to alcoholic excesses and other abuses of the system 
would succumb to an injury of the bones and soft parts from which a younger 
person would readily recover. 
There is occasionally seen, as a result of shot and other contusions, an 
injury of a very deceptive nature, one in which the skin is not necessa- 
rily broken (in consequence of its elasticity and of the bluntness of the vul- 
nerating body), but where the deeper components of the limb, including 
the bones, may be utterly disorganized, and which is soon followed by mor- 
tification. An injury of this kind is disclosed by blebs on the surface of 
the skin filled with bloody serum, by the boggy feel of the parts, by the ab- 
sence of the pulse and a loss of temperature, and by the rapid appearance 
of a purple discoloration. Such are cases requiring amputation. But just 
where to apply the knife, so as to get beyond the limits of the injured tissue, CIRCUMSTANCES DEMANDING AMPUTATION. 
295 
is very difficult to determine. It is important, also, in such cases, that the 
operation be done early. If the surgeon, through indecision, delays inter- 
ference until the inflammatory swelling and tension of the limb which precede 
mortification set in, the conditions, as regards the life of the patient, are ex- 
ceedingly unfavorable for amputation. 
The diseases which affect the bones, and which call for the removal of a limb, 
are caries, necrosis, osteomyelitis, encephaloid and sarcomatous growths, and, 
occasionally, aneurism, enchondroma, and exostosis. Many cases of caries 
and necrosis recover without a resort to so radical a measure as cutting off the 
limb. The employment of a gouge or an acid to remove the disorganized 
bone, or the extraction of a sequestrum from the medullary cavity, is often 
quite sufficient to effect a cure. But there are other cases in which the entire 
thickness of the shaft of a bone for several inches is hopelessly dead, or 
where the whole carpus or tarsus is included in the caries and nothing short 
of amputation can offer any prospect of relief to the patient. Ulcers, malig- 
nant, syphilitic, and benign, may extend in defiance of all medication, internal 
or external, and may be attended with such destruction both of the bone and 
of the superincumbent soft parts that the removal of the limb is absolutely 
demanded. 
Malignant growths which locate themselves in bone do not, as a rule, 
admit of removal in any manner short of amputation of the limb; and 
here, as in similai* disease of the soft parts, the knife should be applied a 
sufficient distance above the tumor to be beyond the visible signs of the 
disease. 
Enchondroma and exostosis, in favorable positions, and when the base is 
not too broad, may be successfully detached by the chisel or the saw without 
sacrificing the limb. 
Injuries and Diseases of the Joints.-Compound dislocations constitute a class 
of injuries which often require amputation, though, in many instances, ex- 
cision can be substituted, with a fair prospect of preserving the limb. If, 
however, in addition to the displacement, the soft parts around the articula- 
tion are extensively lacerated, or if the principal artery of the limb is torn, 
as the popliteal, in a compound luxation of the knee, or the brachial, in a 
similar injury of the elbow-joint, amputation is clearly indicated. 
A joint may be extensively comminuted by a conical ball, or by a grape- 
shot, the lines of fracture extending in one or several directions into the 
shafts of the bones; and, under these circumstances, amputation becomes 
necessary. 
Compound luxation of the knee-joint-except in certain cases occurring 
in children-always demands amputation. 
Diseases of the joints, whether from strumous or traumatic causes, occa- 
sionally call for amputation. The joints most frequently the subjects of 
scrofulous inflammation are the hip, knee, ankle, elbow, and wrist. The dis- 
ease may commence in the synovial membrane, or in the cancellated tissue 
of the articulating ends of the bone, involving, ultimately, all the components of 
the joint, and terminating in caries or necrosis. The success which has usu- 
ally attended excision in cases of chronic joint disease has happily narrowed 
down to a small compass those which require amputation. So that the latter 
operation, at present, is applicable, for the most part, to eases in which ex- 
cision has failed, or where, in consequence of profuse suppuration and hectic 
symptoms, there is a strong presumption that the patient would not endure 
the exhaustion due to the protracted healing after excision, or where there 
is a very extensive destruction of the bones beyond the limits of their articu- 
lating extremities, by which the limb would be left useless after resection. 
As long as there is any prospect of anchylosis taking place in a joint, 
neither excision nor amputation should be practiced, unless in cases where 
the local and constitutional irritation incident to suppuration threatens to 
destroy the life of the patient before the consolidation could be effected. 296 
AMPUTATION. 
Deformities.-A limb may become anchylosed in a posture which will ren- 
der it not only useless, but a serious hindrance to the movements of the patient. 
A toe or a finger may become immovably flexed, so as to embarrass, in the 
one case, the prehensile functions of the hand, and, in the other, the use of 
the foot. When the vicious position cannot be corrected by subcutaneous 
osteotomy or by excision, amputation is the only resort. There are also 
deformities resulting from the cicatricial contractions following scalds or 
burns, from the disability of which the patient can be freed only by ampu- 
tation. 
Aneurism, though generally amenable to pressure or ligation, nevertheless 
sometimes involves the loss of the limb. Thus, in cases of secondary hemor- 
rhage after ligature of the artery, or in suppuration of the sac, followed 
by bleeding, amputation above the seat of the ligation is often our only 
resource. 
In connection with the injuries of the blood-vessels may be mentioned shot 
wounds which sever the chief artery of a limb, as the popliteal or the fem- 
oral. Such wounds will in all probability be followed by the death of the 
limb below the damaged vessel, and will call for immediate amputation. 
Mortification is often the result of injuries implicating both the soft parts 
and the bone. It may also follow the obstruction, embolism, or atheroma of 
an artery, or the pressure of a tumor, and in military hospitals, where large 
numbers of injured men are crowded together, hospital gangrene may ensue, 
in consequence of the entrance of septic matters into wounds. By what- 
ever way induced, the destruction may be so extensive as to necessitate the 
removal of a limb. 
Senile gangrene may be regarded as an exception, as this disease does not 
admit of operative interference. 
In general the surgeon, in cases of mortification, is content to wait until the 
line of demarkation is established before he applies the knife to the limb. 
There are, however, exceptional cases, and for these and other matter con- 
nected with the subject the reader is referred to the remarks on mortification 
(vol. i. pp. 134, 135). 
Malformations.-There are malformations, such as club-foot, which, having 
been neglected during the early period of life, when such deformities are 
almost always capable of correction, become finally sources of serious dis- 
ability, from bursal inflammation and from ulcerations, so that of the two 
evils amputation is the lesser. 
Supernumerary fingers and toes are also proper cases for removal, and the 
operation may be done with perfect safety at two or three months after birth. 
Amputations of expediency should never be undertaken, except under cir- 
cumstances where the disability is considerable or the peace of mind of the 
patient is much disturbed. 
In addition to the various conditions which have been named as consti- 
tuting proper subjects for amputation, others have been advocated by writers, 
such as traumatic tetanus, the bite of venomous serpents and of rabid ani- 
mals. All such suggestions are chimerical, and, I presume, are at present 
never seriously entertained by the surgeon. 
The time at which amputation can he most advantageously executed in 
cases of a traumatic kind is a subject of the greatest moment. Writers at 
present adopt very generally three periods for amputation, or the division 
introduced by Mr. Alcock, viz., primary, intermediary, and secondary, which 
answers to the classification of M. Boucher. 
Primary.-By the primary period is meant that time which elapses between 
Period for Amputation. PERIOD FOR AMPUTATION. 
297 
the reception of the injury and the commencement of the inflammatory or 
traumatic fever. 
Intermediary applies to the period during which the patient is suffering 
from the inflammatory or infective fever incident to the local damage. 
Secondary.-This period commences with the subsidence of the constitu- 
tional disturbance and acute local symptoms and the commencement of sup- 
puration. 
The limits of the primary period may be placed somewhere between five 
and thirty hours. Mr. Skey was disposed to extend the time to thirty-six 
or even forty-eight hours,-a latitude rather too broad, though I believe ad- 
missible in some cases of tardy reaction. 
The primary period is almost universally accepted by surgeons-both civil 
and military-as that in which amputations can be done with the greatest 
prospect of success. There are many reasons for this opinion. (1) The 
morale of a patient who has encountered some injury which requires the re- 
moval of a limb is better shortly after the accident, when the parts are 
measurably devoid of sensibility, owing to the damage sustained by the 
nerves, along with the other components of the limb. (2) The general sen- 
sibility of the system is lowered by the effects of the shock. (3) During 
the period between inflammatory reaction and its termination in suppura- 
tion the life of the patient is jeopardized by many dangers, such as erysipelas, 
pyaemia, mortification, and hemorrhage. 
Nor is every part of the primary period suited for operation. This period 
includes both a state of shock and a state of reaction. It is the degree of 
shock which determines the duration of the primary period, and as long, 
therefore, as the patient remains cold, pallid, and almost pulseless, and covered 
with a clammy perspiration, no operation should be attempted. The auspi- 
cious moment for the knife has arrived whenever reaction has been fairly 
established. 
There is a class of cases in which reaction takes place very slowly, and in 
which the patient will have passed into the intermediary period before it is 
fully established. Rather than allow the case to run the numerous risks 
which endanger life before the secondary period is reached, it is better, pro- 
vided the operation is not one of great magnitude, or one requiring a long 
time for its execution, to proceed to its performance, even though the reaction 
be imperfect. 
The intermediary period is characterized by both the local and constitutional 
signs of inflammation. The limb becomes red, swollen, and sensitive; a 
bloody serum flows from the wound, and the devitalized portions of the latter 
begin to soften and separate. In addition to these symptoms, there will be 
an acceleration of the pulse, a hot, dry skin, persistent thirst, scanty urine, 
coated tongue, headache, nausea, and often some degree of mental wandering. 
This period is extremely ill adapted for amputation, which should never 
be undertaken at this time except under the most compulsory circumstances. 
If to tie an inflamed hemorrhoid, or to excise an inflamed tonsil, is deemed 
reprehensible surgery, when most probably the vascular excitement is wholly 
local, how vastly greater must be the risk to life when an operation of the 
magnitude of an amputation is performed with the tissues of the limb hot, 
tense, swollen, and infiltrated with inflammatory products, and the whole 
mass of the blood aflame under the stimulus of tissue-metamorphosis1 Nor 
are these apprehensions only matters of speculation. On the contrary, 
experience has amply confirmed their reality. (See vol. i. p. 246.) It is, 
therefore, entirely consistent with the soundest maxims of surgery, that when 
from any cause the patient has passed the primary period and entered the 
intermediary, the operation should be postponed until the inflammatory or 
infective fever has passed over and suppuration has commenced,-a period 
which varies from two to three weeks. 
The secondary period is the calm which succeeds the storm. It is introduced 
by the subsidence of fever. The pulse becomes soft and less frequent. The 298 
AMPUTATION. 
skin, which was hot and dry, becomes moist, and thirst abates. The tongue 
cleans off, and the intestinal, urinary, and other secretions assume a natural 
appearance. The desire for food returns, and the patient's cheerfulness is 
restored. The wound and the adjacent parts assume a new appearance,-the 
local redness, tenderness, and swelling disappear, the discharge (at first a 
bloody serum) is replaced by a healthy pus, shreds of dead tissue have been 
detached, and healthy granulations make their appearance. 
And now has arrived that stage which, in its suitableness for amputation, 
ranks next in value to the primary period. Indeed, in not a few instances 
it possesses advantages superior to the primary. It is a matter of common 
observation among surgeons that a patient who has been for weeks or months 
the subject of chronic disease, attended with suppuration and a moderate 
degree of constitutional disturbance, enjoys a sort of immunity from the 
usual accidents following operations, and makes a rapid convalescence. 
History of Amputation. 
It is very difficult to realize that an operation so simple as that of ampu- 
tation required over two thousand years to bring it to its present perfection. 
In accounting for this, two difficulties seem to have been conspicuous,-the 
one anatomical and the other mechanical. The anatomical difficulty con- 
sisted in not understanding the circulation of the blood and in the consequent 
inability to control hemorrhage; and the mechanical perplexity arose from 
the want of sufficient ingenuity to construct a flap which would cover the 
end of the stump. From Hippocrates till the time of Celsus, the surgeon 
simply followed in the wake of nature, never venturing to apply the knife 
for the removal of a limb, except within the limits of the mortified tissues; 
and this rule seems to have prevailed for at least four hundred years. 
Celsus, the prince of Greek physicians, who lived about or shortly after the 
time of Christ, and who appears to have been a theological polemic as well as 
physician and surgeon, introduced the first innovation, by directing that the 
incision should be made between the living and the dead tissues and carried 
down to the bone. In order that the soft parts might be drawn to some 
extent over the stump, he also directed that, before the bone was severed, it 
should be partially separated from the soft parts, so that the saw could be 
applied at a point higher up. His details of the operation extend also to 
removing from the bone any asperities which might be left by the saw. It 
would seem, from the boldness of this procedure, that the use of the ligature 
as a means of controlling hemorrhage was known to Celsus; and this is ren- 
dered probable by the allusions which he makes when treating of wounds, to 
"seizing the bleeding vessel and tying it in two places," and to a passage in 
Cocchius, who speaks of "stitching" bleeding vessels. 
Whether from these passages we are to infer that the ligature was applied 
to the arteries during amputation, or only in wounds of a different kind, has 
been a subject of considerable discussion. Admitting that the thread was 
used at all, it seems quite probable that its application would be more strongly 
suggested after amputation than in any other wound, as nothing could be 
more natural than to seize and tie a spouting vessel, even though the oper- 
ator might know nothing about the order of the circulation. Granting, 
however, that ligation was practiced by the disciples of Celsus, much blood 
must necessarily have been lost during the removal of a limb. This diffi- 
culty was in some measure provided for by Arehigenes, a Syrian, who prac- 
ticed his profession in Rome during the reign of the Emperor Trajan, and, 
consequently, not long after the time of Celsus. This surgeon surrounded 
the limb above the seat of amputation with a cord or band, drawing it 
sufficiently tight to lessen the effusion of blood while the incisions were being 
made. To diminish the bleeding still further, he applied cold water to the 
entire limb. Archigenes's attempt was the earliest in the construction of a 
tourniquet. He does not appear, however, to have followed the precepts of HISTORY OF AMPUTATION. 
299 
Celsus, in respect either to hemorrhage (by tying the vessels) or to separating 
the soft parts from the bone and dividing the latter high up, so as to procure 
a covering for the stump. He controlled hemorrhage by the use of a hot 
iron, and had the soft parts well drawn up before their division, so as to 
secure the necessary flaps. 
For a long period after this the surgery of amputation appears to have 
retrograded. Galen, who, through its native timidity or its reverence for 
ancient authority, ruled the profession as with a rod of iron for fourteen 
centuries, inculcated the Hippocratic doctrine of confining the incisions to 
the dead tissues and treating those portions nearest to the living flesh with 
the actual cautery. 
The Arabians followed the teachings of the Greeks. Thus, we find Paulus 
JEgineta and Avicenna advising the division only within the mortified parts. 
Albucasis, with more boldness than his contemporaries, approached the 
sound tissues, using, in order to prevent hemorrhage, a red-hot knife for 
dividing the soft parts. During the long period which succeeded the fall of 
the Roman Empire-the mediaeval ages-medicine and surgery made no 
progress. The cloister became the depository of what little learning remained, 
and the clergy employed the resources of surgery more for their personal 
distinction than from any scientific zeal. Indeed, some of the edicts which 
were promulgated by "the spiritual head of the Church," as that of Boniface 
VIII., rendering it unlawful for the clergy to engage in anything which was 
connected with the shedding of blood, were calculated to prevent any im- 
provement whatever in the surgical branch of medicine. 
In consequence of the introduction of gunpowder, in the fourteenth century, 
war became more destructive. It is impossible to conceive of the dreadful 
suffering and loss of life following the sanguinary conflicts of this period in 
consequence of the degradation to which surgery had been consigned. It 
was towards the close of the Middle Ages that Gui de Chauliac devised the 
plan of bloodless amputations, by first enveloping the limb in a thick coating 
of pitch and then encircling the member at one of its articulations with a 
cord, which was tightened to a degree which insured the mortification of the 
parts below the seat of constriction. 
When the long night of ignorance and barbarism began to disappear in 
the latter part of the fourteenth and the beginning of the fifteenth century, 
medicine, in common with letters in general, was transfused with new life. 
Anatomy, the only true basis of surgery, made singularly rapid progress. 
At this epoch appear the distinguished names of Vesalius, Fallopius, Eusta- 
chius, and others familiar to the student of medicine; but, with all the 
achievements of these eminent scholars, the problem of controlling hemor- 
rhage remained unsolved. Thus, we find Fabricius ab Acquapendente and 
Fabrieius Hildanus advocating the cautery as the great hsemostatic. The last- 
named surgeon, in the early part of his career, used the red-hot knife for the 
purpose of dividing the tissues and at the same time searing the blood-vessels. 
As late as the middle of the seventeenth century limbs were removed by 
the chisel and mallet. As celerity of operation was deemed a vital matter, 
in consequence of the loss of blood, it was during this period that Botalli 
invented his guillotine, consisting of a sharp, heavy axe, which, being allowed 
to fall from a height upon the limb, severed it instantaneously at a single 
blow. At the time of Richard Wiseman, the common mode of amputation 
was first to encircle the limb tightly with a cord, for the double object of 
preventing hemorrhage and of benumbing the limb. The integuments were 
next drawn strongly upward by an assistant, after the manner of Celsus and 
Archigenes, so as to procure material for a flap with which to cover the 
stump. A knife was then carried swiftly around the limb, dividing the soft 
parts to the bone, after which the latter was cut through with a saw, and 
the bleeding controlled by the hot iron. 
It was about the year 1579, or in the last quarter of the sixteenth century, 
that Ambrose Pare discovered or revived the use of the ligature for the arrest 300 
AMPUTATION. 
of bleeding in amputation. In removing a limb this surgeon forcibly retracted 
the soft parts, and retained them so with a bandage drawn strongly about the 
member. This bandage fulfilled a threefold purpose, namely, the retention 
in place of the retracted soft parts, the compression of the blood-vessels, and 
the diminution of sensibility by pressure of the subjacent nerves. The 
knife was next applied to the skin immediately below the fillet or band, and 
carried down to the bone; and when the operation was performed on the leg 
or the forearm, the interosseous structures were divided with a smaller knife. 
This done, the bones were cut through with a saw at as high a level as possi- 
ble, and the arteries drawn out with forceps (including, in some instances, 
the surrounding tissues), and each tied with a double ligature. The vessels 
having been secured, the band was next detached from the limb, the soft 
parts drawn down over the wound, their edges drawn towards each other, 
and so maintained by the sutures. 
The ligature, therefore, used by Pare, had it been accepted by bis contem- 
poraries, would at once have rendered unnecessary the formidable cauterizing 
irons, with all the evil consequences attending their use. Instead, however, 
of this being the case, not only was it repudiated by Pare himself, but it was 
subjected to abuse without measure, so that almost a century elapsed before 
the ligature was employed in France for the arrest of hemorrhage, chiefly 
through the advocacy of Dionis. 
The first part of the seventeenth century was made forever memorable by 
the discovery of the circulation of the blood by Harvey. Like the ligature 
of Pare, the public announcement of the movement of the heart and blood, 
which was made in 1628, subjected its author for a time to ridicule and abuse, 
which ceased only when the demonstration of the discovery became fortified 
by an invincible accumulation of facts. 
A natural result of the discovery of the circulation was the invention, in 
1674, of the tourniquet, by Morel, a French surgeon. It was devised during 
the siege of Besangon, and may therefore be justly credited to military sur- 
gery. The instrument consisted of a band, which was placed around the 
limb and tightened by passing underneath it a stick and turning the latter 
until the necessary degree of constriction was obtained. This rude con- 
trivance no doubt suggested the instrument devised by Petit, another 
French surgeon, forty-four years later (in 1718), which is essentially the 
tourniquet in common use at the present day. It is remarkable how this 
old instrument, with its acknowledged defects, has so stubbornly retained 
its popularity in defiance of many substitutes which have been invented. 
The example of Dionis in France, in regard to the use of the ligature, was 
followed in England by Bichard Wiseman, and in Germany by Hildanus. 
Two great achievements, however slow in being attained, had at length 
been accomplished,-the control of hemorrhage during the process of an 
amputation by the tourniquet, and the closure of the vessels after the operation 
by the ligature. 
The operation, nevertheless, was still very imperfect, in that surgeons had 
as yet not been able to construct a covering for the stump. And this brings 
us to speak of the different methods of amputation. 
Various Methods of Amputation. 
However various the plans of amputation, they may all be embraced under 
two general heads,-the tegumentary and the musculo-tegumentary. 
Tegumentary Method.-This method is executed in two ways,-by a circular 
flap or by oval flaps. 
Circular Tegumentary Flaps.-Amputation by this method may be 
divided into three stages,-the division of the integument, the division of the 
muscles, and the division of the bones. First, the surgeon, standing on the 
outside of the member to be removed, provided he be ambidexter, and stooping TEGVMENTARY METHOD. 
301 
down, passes his hand beneath and around the limb, holding the knife lightly 
between the thumb and the index and middle fingers of the hand, and applying 
the middle of the blade to that sur- 
face of the limb which looks towards 
the operator. (Fig- 1128.) The in- 
strument is now carried rapidly 
round the member, ending with the 
heel of the knife at the point of 
beginning, and dividing perpendicu- 
larly the skin and superficial fascia 
down to the deep fascia. Any points 
where this is not effected can be 
readily incised by a few touches 
with the edge of the instrument. It is 
sometimes advised that the operator, 
previous to and while making the 
circular division of the integument, 
should draw the latter upward with 
the other hand. This preliminary 
measure is a matter of personal preference, and may or may not be adopted, 
according to the pleasure of the operator, as it possesses no special advantages 
in this method of amputation. The division of the integument is promptly 
followed by its retraction, leaving a considerable gap between the two sides 
of the wound. A gush of venous blood also occurs at the moment the skin 
is cut through; but this ceases as 
soon as the engorged trunks are 
unloaded. 
The integument is next dis- 
sected up from the deep fascia and 
reflected, as one rolls back the cuff 
of his coat-sleeve. (Fig. 1129.) 
This is done either with the point 
of the amputating-knife, or with 
the scalpel, and to an extent 
greater than is necessary to covei- 
the raw surface of the stump. In 
raising the integument, the edge 
of the knife must be directed 
against the deep fascia, so as to include all the subcutaneous adipose tissue 
in the flap. The exact amount of this flap must be determined by the eye 
of the surgeon, as it is both awkward and inartistic to be compelled to resort 
to measurements. If the limb at the place of operation measures twelve 
inches, its diameter will be four inches, and a flap two and a half inches on 
each side will be required. 
Second.-The integument being now reverted and held out of the way by 
the operator or his assistant, the knife is applied to the limb on a level with 
the base of the reflected integument, and made to divide the deep fascia and 
muscles down to the bone, with the same circular sweep as in the first in- 
cision. If the amputation is being done on the leg or the forearm, the next 
step consists in passing a narrow catling between the two bones, and, after 
dividing the interosseous structures, carrying the instrument around each 
bone separately, so as to sever all its connections wTith the soft parts and the 
periosteum. 
This done, the middle strip of a three-tailed retractor is pushed with the 
finger or the forceps through the interosseous space, the other strips being 
crossed, and all three gathered together and drawn up on one side of the 
wound, while the undivided end of the retractor is pulled up on the other 
side and both ends intrusted to the hand of an assistant, who in this manner 
holds the soft parts out of the wTay while the bones are being divided. 
Fig.1128. 
Position of the knife in beginning the circular incision. 
Fig. 1129. 
Circular flap dissected from the deep fascia and reflected. 302 
AMPUTATION. 
Third. The third and last stage consists in the division of the bones. This 
is a part of the operation which requires great care in its execution. 
The operator himself, and not an assistant, should always grasp that por- 
tion of the limb which is to be removed, with one hand, while he plies the 
saw with the other. In this way the two hands co-operate in such a manner 
that the saw does not become locked in the groove made by its teeth, in 
consequence of the distal part of the limb being raised too much, nor are the 
fibres of the bone broken without being cut, as would be the case if the ampu- 
tated portion were permitted to sink prematurely. 
No attempt should be made to force the saw into the bone. It should be 
allowed to cut only by its own weight. And it should be driven by a steady, 
long, to-and-fro movement. The saw is best used in the horizontal position, 
with a single exception,-that of amputation of the leg, when it can be applied 
most conveniently between an oblique and a vertical position. It is desirable 
also here, as in the arm, that both bones should be severed simultaneously; 
but, if this is not done, the smaller and more movable bone of the two (the 
fibula) should be first divided, as, by observing this rule, there is less danger 
of breaking the osseous tissue. 
Before sawing the bone, Dr. McGill, U.S.A., has suggested raising two peri- 
osteal flaps with which to cover the end of the bone. This has been done 
in several instances, and with very satisfactory results. It tends to protect 
the medullary tissue of the bone against the intrusion of inflammatory and 
other products which might endanger the life of the patient. 
When the soft parts are divided by the double incision, the stump will 
present very much the appearance repre- 
sented in Fig. 1130. The different degrees 
of retraction of the superficial and deep 
strata of muscles depend on the fact that 
the former are much more loosely con- 
nected with the subjacent parts than the 
latter. 
Modifications of the circular operation.- 
To provide against the unequal retraction 
of the muscles and secure a uniform plane 
to the stump, as well as to save pain, by 
not raising the integument from the deep 
fascia, Louis, a French surgeon, practiced 
a modification of the double incision. After 
drawing up the skin and applying a band around the limb immediately above 
the place where the knife was to be applied, Louis made the first cut through 
the integument, the deep fascia, and the superficial layer of muscles. That 
these parts might be allowed to retract to the uttermost, the constricting cord 
was now removed, and the deep layer divided on a level with the superficial 
stratum, thus enabling him to cut the bone off high up. Dupuytren was also 
in the habit of cutting the integuments and superficial layer of muscles at a 
single incision. 
All of these operations, however, very imperfectly fulfilled the great neces- 
sity,-that of forming a sufficient covering for the stump. Several names are 
associated with this last achievement. Those deserving special prominence 
are Loudham, Cheselden, Alanson, and Petit. The claim of priority appears 
to belong to Loudham, of Exeter, England. A letter was written to a sur- 
geon in London, Thomas Hobs, in 1678, in which (after describing an oper- 
ation by which a tegumentary flap taken from the calf of the leg was 
brought ovei' the surface of the stump and united by sutures to its edge, 
securing healing, and preventing exfoliation of bone), the writer goes on to 
say that he had learned the method from Mr. Loudham. This lettei' was 
written one hundred and one years before the writings of Alanson, which 
were published in 1779. 
Fig. 1130. 
Appearance of the stump after the usual circular 
operation. TEGUMENTARY METHOD. 
303 
Alanson's plan of dividing the muscles in the form of a hollow cone was, 
however, an original idea. 
Cheselden brought up again what has been improperly called the method 
of Celsus,-dividing the integument, and. after drawing it up, making a 
second cut on a level with the retracted skin and cellular tissue down to the 
bone, in order that the bone might be sawed as high up as possible. But the 
operation of Cheselden differed from that of Celsus in a very important par- 
ticular, viz., that not only was the skin divided and drawn up, but it was 
also dissected loose from its subjacent attachments, which necessarily in- 
creased the amount of tegumentary covering. This operation has also been 
attributed to Petit. 
The great tension to which the soft parts were subjected by these plans of 
operation, in order that they might be brought together over the bone, ren- 
dered their union very precarious. And hence conical stumps and the pro- 
trusion of bone were very common occurrences. To obviate this, Mr. Alanson 
devised the plan of cutting the muscular components of the limb (after dis- 
secting up a sufficient amount of integument to cover the end of the stump) 
so as to form a hollow cone, its apex being upward, and answering to the 
point where the bone is to be cut off. The operation was applicable only to 
thigh amputation. 
Triple incisions were practiced by Desault and Iley. The first extended 
through the integument; the second on a level with the retraction of the 
latter and through the superficial muscles; and the third through the deep 
layer to the bone, on a plane with the first. 
Oval Tegumentary Flaps.-An objection which may be urged with con- 
siderable force against the ordinary circular operation is the difficulty, or 
rather impossibility, of folding back or reverting the integument in certain 
portions of the extremities (as at the middle of the leg or forearm), in conse- 
quence of their rapidly increasing size as we ascend. A slit in the integu- 
ment, on opposite sides, will obviate the difficulty; but these cuts detract 
from the appearance of the covering. To meet this objection the oval tegu- 
mentary flap method was introduced by Syme. 
This operation is done by making two semilunar incisions on opposite sides 
of the limb down to the deep fascia, and dissecting up the integument to an 
extent sufficient to cover the stump. In the forearm, in the leg, and in the 
thigh the flaps should be raised from the anterior and posterior aspects of the 
limb; in the arm, from the outer and inner surfaces; and they are occasionally 
made of unequal lengths,-the longer of the two being turned down or brought 
up over the end of the bone, according as the circumstances of the case re- 
quire. In lacerated wounds of the extremity requiring amputation, it may 
be necessary to form more than two flaps, and often, in similar injuries of the 
hand, only a single flap can be obtained. 
These flaps being reflected, a circular cut is next made through the muscles 
down to the bone, on a level with the reflected skin and cellular tissue. Or, 
if the amputation is being done on the thigh or the arm, the two layers of 
muscles may be divided separately, so as to compensate for their unequal re- 
traction. At the tw'o points where the elliptical incisions join, or at the an- 
gles of the wound, the integument should be raised a short distance from the 
subjacent parts, in ordei' 
that the bones shall not 
project at these points 
after the approxima- 
tion of the flaps. (Fig. 
1131.) 
When the forearm or 
the leg is the part to 
be removed, the inter- 
osseous structures are next to be divided by the catling; or, if the arm or 
the thigh is the subject of the operation, the knife must be carried round 
Fig. 1131. 
Oval tegumentary flaps reflected and dissected up at their angles. 304 
AMPUTATION. 
the bone. In either case the knife should divide the periosteum, since without 
this precaution the teeth of the saw are liable to detach that membrane 
unnecessarily from the bone. 
Single tegumentary flap, or the method of Carden.-Mr. Carden, of Worcester, 
England, in 1846, introduced an operation which possesses a high practical 
merit in certain localities,-e.g., when it becomes necessary to remove the 
thigh above the knee. By adopting the plan of this surgeon, a covering 
can be taken from the front of the joint, by which the amputation can be 
made through the bases of the condyles instead of through the lower third 
of the femur,-a matter of vital importance, as it will necessarily diminish 
the mortality of thigh amputations. 
This method consists in raising a long, rounded, anterior flap of integument, 
without any posterior flap, dividing the remaining soft parts, and, after draw- 
ing up the latter, cutting off the bone with the saw. The long, anterior 
tegumental flap is then brought down over the face of the stump like a hood, 
without being folded back. 
Musculo-Tegumentary Method.-By this plan the flaps are composed of both 
integument and muscle ; in other words, include all the soft parts of the limb. 
They are sometimes taken from both aspects of the limb (Jbi-musculo-tegu- 
mentary), as in amputations of the arm, the forearm, and the thigh, and pre- 
sent, when properly fashioned, an inverted V-shaped figure. Or one flap 
alone may be musculo-tegumentary, and the other semi-musculo-tegumentary, as 
is usually done in amputation at the middle or in the upper third of the leg, 
the former being constructed from the back, and the latter from the front, of 
the limb. The flaps may also have a rectangular shape. 
Bi-musculo-Tegumentary Flap.-There are three modes of performing 
this operation. In one, the division of the soft parts is made from within 
outward, after the manner of Vermale, and in the other from without in- 
ward,-a plan preferred by Langenbeck; while Luke embodied both methods 
in his procedure, which consisted in cutting one flap from within outward 
and the other from without inward. These flaps are not always formed of 
the same lengths. As a rule, each flap should be equal to at least three-fourths 
the diameter of the limb. 
Operation.-After adopting the necessary precaution against hemorrhage 
by applying the tourniquet, the integument is drawn well up by an assistant, 
when the operator, grasping with one band the soft parts on one or other 
aspect of the limb, raises them up from the bone, and with the other hand 
passes a sharp-pointed amputating knife through the base of the mass so 
raised, from side to side, shaving the bone as the transfixion is made. The 
knife is now carried downward and forward by a sawing movement, and 
brought obliquely out on the surface, making a semi-oval flap; or, if the 
surface to be covered is a broad one, by cutting directly downward to the 
requisite extent and then abruptly outward, forming a square flap. After the 
completion of the first incision, an assistant seizes the flap, and, holding it out 
of the way, compresses with his fingers any vessels of magnitude that may 
be bleeding. 
The surgeon now enters his knife at the angle of the wound on one side, 
and brings it out at a similar point on the other side, passing across that 
aspect of the bone opposite to the first transfixion, and cutting downward 
and outward by the same movement of the knife as was practiced in making 
the first flap. The appearance of the wound after the completion of these 
incisions is represented in Fig. 1132. In forming these musculo-tegumentary 
flaps, the one which contains the chief vessels of the limb should be divided 
last, so that as little blood as possible may be lost should the circulation 
through the limb not have been thoroughly controlled by the tourniquet. 
In transfixion, it is important that the knife be carried steadily through 
from side to side, without being withdrawn and again advanced, as is some- 
times done when the point becomes arrested against the bone. The blade OVAL METHOD. 
305 
should be made to glide over the latter by altering the position of the handle. 
For if it be drawn back and again thrust onward, a second wound is inflicted, 
which may involve a considerable vessel, 
or may wound the same vessel in a second 
place, and thus give rise to a troublesome 
bleeding. 
The flaps being now held back, the 
knife is quickly carried around the bone 
at the apex of the wound, in order to 
divide any remaining portions of the mus- 
cular tissue which may have escaped the 
first incisions, and also to cut through the 
periosteum. As the flaps can be readily 
drawn back by the hands of an assistant, 
the retractor is not necessary for their 
protection, and the saw can at once be 
applied to the bone. 
When the incisions are made from with- 
out inward, the knife divides first the skin, 
and is carried upward and inward, or in directly the reverse direction of the 
operation by transfixion. 
Author's Modification.-As, after division of the soft parts by transfixion, 
the skin is found to retract much more than the muscles, leaving the latter 
hanging some distance below. I have been in the habit, in order to avoid 
this inconvenience, of first raising two elliptical tegumentary flaps for a 
little distance, and then pushing the knife at the angles of the wound be- 
tween the muscles and the bones, and cutting downward and outward, first 
on one side and then on the other, terminating the incisions at the line where 
the tegumentary flaps are attached. 
(Fig. 1133.) When the latter are re- 
verted, the skin and muscles will be found 
to be of the same length. 
Fig. 1132. 
Appeal since of the wound after the formation of 
the bi-musculo-tegumentary flaps. 
Fig. 1133. 
The Oval Method, so termed by Scou- 
tetten, is a bi-musculo-tegumentary oper- 
ation, which is chiefly applicable to am- 
putation at certain articulations, as those 
of the metacarpo- or metatarso-phalan- 
geal joints, and also at the shoulder. 
The flaps are usually formed by cutting 
from without inward, or one may be 
fashioned in this way and the other from 
within outward. 
In case of a metacarpo-phalangeal 
articulation, the point of the knife is 
applied usually a little above the joint, 
and, after being pushed down to the 
bone, is carried downward, gradually 
diverging from the mesial line to one 
side, and finally terminating at a point 
on the palmar surface nearly opposite 
the place of commencement. A similar incision is next made on the 
opposite side of the articulation, commencing and ending at the first. 
When completed, the wound presents an oval appearance or resembles 
somewhat two V's with their bases resting together. The operation is a 
good one, and the wound is one admitting of a very neat and accurate 
adjustment. 
Author's modification of the flap method. Skin 
raised and reflected and muscles transfixed. The 
dotted line indicates where the muscles are to be 
cut out. Above, skin and muscle, both reverted. 
Semi-Musculo-Tegumentary Method-This operation consists in forming 
vol. ii.-20 306 
AMPUTATION. 
from one aspect of the limb a musculo-tegumentary flap, and from the other 
a tegumentary flap. 
The plan is well adapted to amputation through the middle or upper por- 
tion of the leg, the calf of the limb furnishing abundance 
of material for the construction of the musculo-tegu- 
mentary covering, and the anterior surface supplying 
the tegumentary flap. (Fig. 1134.) 
Fig. 1134. 
Quadrangular Musculo-Tegumentary Method.-This 
method has been practiced in two ways,-the one known 
as that of Ravaton, the other that of Teale. 
Ravaton's plan (1739) consisted in first making a cir- 
cular incision through all the soft parts down to the 
bone, and next two vertical cuts leading directly up 
from the first, one on either side, and extending also as 
deep as the bone. The two symmetrical flaps were next 
dissected up, reflected, and the bone sawed off on a line 
with their reflection. 
Teale's plan (1855) differs from Ravaton's chiefly in 
the flaps being of unequal length, one long and the other 
short. The first was planned so as to contain the prin- 
cipal blood-vessels and nerves. The second, or long flap, 
was employed to cover the end of the bone. The rule 
for forming these flaps was as follows: the long one, 
which should be first cut, must equal in length one-half the circumference 
of the limb at the seat of operation, while the short flap is required to be 
one-fourth the length of the long one, or one-eighth the circumference of 
the limb. It is usual, before cutting these flaps, to trace the lines of incision 
wfitli ink, with a view to secure greater accuracy in their construction. (Fig. 
Semi-muscul o-tegumentary 
flap. 
Fig. 1135. 
1135.) After dissecting up and reverting the flaps, the bone is to be sawed 
off, and, after the ligation of the vessels, covered, by bringing over its ex- 
tremity the long flap, the end of which is to be attached by sutures to the 
end of the short one. The sides of the two flaps are also to be connected by 
sutures, as well as the contiguous borders of the long flap to each other. 
(Fig. 1136.) 
Wharton's modification of the rectangular method.-In 1868, Mr. Wharton, of 
Dublin, suggested a modification of Mr. Teale's rectangular operation, which 
consisted in forming only a single flap, and sawing off the bone on a level 
Lines of incision in Teale's rectangular amputation. COMPARISON OF METHODS. 
307 
with what would be the lower portion of the short flap according to the 
Teale plan. The operation has been favorably spoken of by Maypother, 
Macnamara, and other distinguished Irish surgeons. 
This is much the same operation as that practiced by Mr. Spence, of Edin- 
burgh, ten years previous. 
History.-About the year 1706, a surgeon of Amsterdam, Verduin, in an 
amputation of the leg, devised a musculo-tegumentary flap which he took from 
the calf of the limb, by 
passing a knife through 
from side to side between 
the gastrocnemius and so- 
leus and the bones, and 
cutting downward and 
outward to the surface. 
The single muscular flap 
was brought up in front 
of the stump and firmly 
pressed against its surface, 
where it was held by a 
peculiar instrument, with 
the double object of se- 
curing a covering for the 
wound and of controlling 
by pressure the bleeding 
from the vessels. 
In 1750, Garengeot, in 
an amputation of the arm, 
formed double musculo-tegumentary flaps by taking one from either side, 
and, after tying the vessels, placed these flaps over the end of the stump, 
securing them at the same time with a bandage. 
Lastly, Vermale, in 1767, introduced the operation now generally adopted 
in amputating by the musculo-tegumentary plan, viz., that of pushing the 
knife through from one side of the limb to the other in close contact with the 
bone, and, after cutting a flap downward and outward on one aspect of the 
limb, repeating the same procedure on the other aspect. 
Fig. 1136. 
Appearance of the flaps when adjusted after Teale's operation. 
Comparison of Methods.-Tegumentary Flaps.-The objections which have 
been urged against the tegumentary flap are, the time required for its execu- 
tion, the danger to the vitality of the flap, the difficulty of reverting the 
latter in some parts of the limb, and the puckered character of the cicatrix. 
Before the introduction of anaesthetics the first objection was a valid one, as 
the operation of cutting through the skin and dissecting up and turning back 
the integument was not only exceedingly painful, but was necessarily the 
work of some little time. Now, however, the different stages of forming this 
covering can be executed deliberately, and without the patient's consciousness 
of any suffering. 
The second objection, or the danger to the life of the flap, is still valid. 
The raising of the integument from the deep fascia can only be accomplished 
by the division of hundreds of vessels, which serve to connect the skin with 
the subjacent parts, so that the work of nutrition of the flap is entirely de- 
pendent on the presence of those arteries which remain intact at the line 
where the integument is reflected, and which, in long flaps, may prove en- 
tirely inadequate to furnish the necessary supply of blood. The plan which 
I frequently adopt, of raising the integument only for a short distance, and 
afterwards cutting a muscular flap, diminishes in a great measure the risk 
from this source. In wounds attended with much contusion tegumentary 
flaps cannot be regarded as trustworthy. 
The third objection (the difficulty of reverting the flap where the circum- 
ference of the limb rapidly increases from below upward) is one of little force, 308 
A MP UTA TION. 
as it applies only to the circular operation, and even in this is quickly re- 
moved by making a vertical slit in one or both sides of the integument. 
The fourth objection is that which takes exception to the cicatrix. In the 
circular flap, after union has been completed, the cicatrix contracts to a cen- 
tral point, from which the skin radiates in plicated folds. The intermediate 
creases or depressions may become chafed by the moisture in hot weather, 
macerating the skin. A little attention to cleanliness will obviate this when 
it does occur; and as to central disposition of the cicatrix,I cannot conceive 
of any reason why it should be more objectionable than a linear one. 
The advantages claimed for the method are, that the flaps, containing no 
muscular tissue, are not liable to become separated after their adjustment by 
the contraction of the muscles; that, for the same reason, the danger of bone 
protrusion or of a conical stump is diminished ; that deep-seated suppurations 
are less likely to occur; and that necrosis, neuralgia, and secondary hemor- 
rhage are rendered less probable. These advantages, however, are by no 
means peculiar to this plan of operation. 
Musculo-Tegumentary Flaps.-The advantages claimed for the musculo- 
tegumentary flap method are, the great rapidity with which it can be per- 
formed, and the large cushion of tissue which it furnishes for the end of 
the stump, which renders the latter better capable of sustaining the weight 
of the body. 
With reference to the celerity with which a limb can be removed by the 
above method, it has been shown that the question of time is less important 
now than formerly, when anaesthetics were unknown. 
Nor does the massive cushion of muscle remain as a permanent covering 
for the stump. It gradually becomes atrophied, and finally disappears, leav- 
ing only the connective tissue which served to hold together the fasciculi. 
Even if the muscular tissue did remain, it would prove an evil rather than a 
benefit, as the persistent contractions of its fibres would finally render the 
covering of the stump tense, and probably cause its ulceration. Nature does 
not often err in her plans of repair. Indeed, no cushion is wanted on the ends 
of a bone, as the mechanician in adapting an artificial substitute for a lost 
member distributes his pressure over the circumference, not at the end of 
the limb. 
The disadvantages which have been urged against this flap method are, 
the oblique direction in which the vessels are cut, the risk of secondary hem- 
orrhage and of neuralgia, the great extent of the wound, and, consequently, 
the delay in healing. 
There is some force in the first objection, as the vessel may be shaved or 
slit for some distance, or it may be wounded in more than one place, and 
therefore may not be tied above the highest opening. This difficulty is far 
from being of an insuperable kind, as it will be removed by a little addi- 
tional care in ligation. It is not true that secondary hemorrhage is more 
frequent after amputations by the musculo-tegumentary flap than by the 
tegumentary. Nor is the extent of the wound or the time consumed in 
healing any greater in the former than in the latter method. 
Most of the neuralgic or painful stumps which have come under my obser- 
vation have been in limbs amputated by the tegumentary method; though I 
am disposed to believe this troublesome condition was not at all dependent 
on the mode of operation. 
Teale Method.-The plan of forming rectangular flaps is one which, in 
many instances, will prove satisfactory. But it has disadvantages which will 
militate against its being generally accepted. Operations requiring for their 
proper performance preliminary measures and tracings arc not likely to be- 
come very popular. The extensive division of tissue which is demanded by 
the Teale method, greater than by either the ordinary tegumentary or the 
musculo-tegumentary method, protracts the period of healing. In addition 
to this, there is an unnecessary amount of bone sacrificed. 
In illustration of this last fact, let us suppose an amputation of the thigh OPERA TION. 
309 
becomes necessary from injury or disease of the knee-joint. By Carden's 
method the limb could most probably be removed at the base of the condyles; 
by the ordinary musculo-tegumentary flaps, two inches higher; but by the 
rectangular plan, assuming that the circumference of the thigh would be four- 
teen inches, the bone would require to be cut seven inches up, which would 
seriously detract from the leverage of the limb, as well as add to the mor- 
tality of the operation. It may be estimated that for every inch lost in the 
formation of the long flap twice that amount of bone must be sacrificed,-an 
objection that must weigh heavily against this plan in many cases of lacerated 
wounds requiring amputation. 
Carden's Method of one long integumental flap has only a local value, 
namely, in condyloid amputations of the thigh. To extend it beyond this 
would be to endanger the life of the flap. 
Conclusion.-When we come to sum up and compare the advantages and 
disadvantages of the two general methods of amputation, the results are very 
nearly balanced. 
Indeed, no single method can be wisely adopted by a surgeon as applicable 
to all portions of the extremities. In some localities tegumentary flaps will 
be found best adapted to cover the stump, while in other parts of a limb 
the musculo-tegumentary, in some of its modifications, will prove most satis- 
factory. 
At the lower third of the leg, and in the forearm near to the wrist-joint, 
where tendinous structure predominates, I much prefer a tegumentary flap; 
while in the thigh, at the upper two-thirds of the leg, and in the arm, I often 
employ the musculo-tegumentary flap. 
Operation. 
Under the head of the operation of amputation we consider the instru- 
ments to be used, the position of the patient, the number of assistants neces- 
sary, and the dressing of the stump. 
Instruments.-The instruments and other appliances usually required for 
the operation are a tourniquet, a 
large-sized scalpel, a forceps, an am- 
putating knife, a catling, saws, and 
bone pliers, an artery forceps or a ten- 
aculum, and a retractor, together with 
sponges, towels, ligatures, needles, 
lint, and rollers. These implements, 
etc., should be arranged, previous to 
the operation, on a tray or waiter, 
over which has been laid a towel, in 
order that the edges of the instru- 
ments may not be injured. The tour- 
niquet generally employed is that of 
Petit (Fig. 1137), which has been par- 
ticularly described in vol. i. (page 
161). 
The amputating knife varies from 
seven to thirteen inches in length; 
its breadth is from three-eighths to 
half an inch; it should have a stout 
back, with a strong handle, which, 
instead of being rough, as it is usually 
made, should be smooth, in order that 
no foreign matter may adhere to its 
surface. (Fig. 1138.) The catling is 
a double-edged instrument, and, like the amputating knife, varies in length 
from seven to nine inches. (Fig. 1139.) It is designed to pass between the 
Fig. 1137. 
Tourniquet. 310 
AMPUTATION. 
bones, in order to divide the interosseous structures, and should never 
Fig. 1138. 
Three sizes of amputating knives. 
exceed three-eighths of an inch in width, as otherwise it cannot be con- 
veniently used. 
Fig. 1139. 
Long catling. 
The two instruments-amputating knife and catling-can, where economy 
Short catling. 
Fig. 1140. 
Catling and amputating knife combined. 
is an object, be combined in one (Fig. 1140), the double edge being restricted 
to three inches in length from the extremity of the blade. 
Fig. 1141. 
Amputating saw. 
The saw in common use resembles either the dovetail- or the jig-saw of 
Fig. 1142. 
Amputating saw. 
the carpenter. (Figs. 1141, 1142.) For amputations of the hand or foot, OPERATION. 
311 
a smaller saw will be required, the back of which is movable and can be 
raised from the blade. (Fig. 1143.) The teeth of the saw should be set in such 
a way that the instrument will cut during both the forward and the back- 
ward movement. 
Fig. 1143. 
Small-sized amputating saws. 
The bone pliers are designed to remove any irregularities which may be 
left by the saw on the end of the bone. (Fig. 1144.) 
Fig. 1144. 
Bone pliers. 
A large-sized scalpel (Fig. 1145), to raise the integument when forming 
skin flaps, a pair of forceps and a tenaculum, to seize and draw out the ves- 
Fig. 1145. 
Scalpel. 
seis for ligation, conclude the summary of the instruments required for an 
amputation. 
Fig. 1146. 
Amputating case. 
An amputating case, with its contents, is very well represented in Fig. 1146 312 
AMPUTATION. 
Position of the patient.-The patient must be placed in the recumbent posi- 
tion, on a firm table covered with a mattress or with some folded comfortables 
and protected by a gum- or oil-cloth : or, if a table is not convenient, on a bed, 
with the limb to be removed projecting from its side. 
Assistants.-The number of assistants that can be employed with advan- 
tage in major amputations is three, distributed as follows: one to administer 
the anaesthetic, one to support the limb, and one to hand and receive instru- 
ments; the latter can also assist in the ligation of the arteries. These are 
to be disposed in such a manner as not to interfere with one another. (Fig. 
11470 
Fig. 1147. 
Disposition of surgeon and assistants in performing an amputation. 
Controlling the Circulation.-Two or three turns of a bandage being 
passed loosely around the limb, the body of the roller, acting as a compress, 
should be placed longitudinally over the principal artery, and upon it the 
base of the tourniquet is adjusted, and the strap of the instrument buckled 
around the limb. Before tightening the tourniquet, the parts should be 
emptied of blood as much as possible, by elevating the extremity and com- 
pressing the artery with the thumbs at a point where the circulation can be 
most easily controlled, as against the horizontal ramus of the pubic bone in 
leg or thigh amputations, along the inner edge of the biceps muscle in fore- 
arm and arm amputations, or, when the operation is demanded near the 
shoulder, by pressing the subclavian artery against the first rib above the 
clavicle. As this pressure, when applied accurately on the vessel, does not 
interfere with the return circulation through the veins, the limb can be soon 
drained of its blood, especially if the process is aided by rubbing the super- 
ficial venous trunks with the hand from below upward. 
As soon as the vessels become emptied, the tourniquet must be screwed 
down with sufficient firmness to interrupt the circulation in the limb and to 
maintain the advantage thus gained. If this plan is properly carried out, 
very little blood will be lost in the operation. OPERA TION. 
313 
Some surgeons dispense with the tourniquet altogether, and depend on 
digital compression for commanding the artery, or use, instead thereof, Es- 
march's elastic bandage. The first is unreliable, as it leaves the vessel in 
charge of a force which can rarely be unremittingly maintained for any con- 
siderable length of time, and is consequently inefficient, besides requiring for 
its execution an additional assistant. By the second plan, that of the elastic 
strap, the limb can be rendered bloodless, but it is followed by so much 
oozing of blood from the sudden distention of the vessels after the removal 
of the band, that an excessive number of ligatures is required, as well as the 
consumption of much time in controlling the bleeding. For these reasons I 
discard the rubber bandage, except in circumstances which will be noticed 
under the head of special amputations. 
Ligation of the Arteries.-After the operation has been completed, the 
surgeon proceeds to tie the vessels. Their position on the face of the stump 
can be readily determined by recalling their anatomical relations. If they 
cannot be located or identified in consequence of their being buried in the 
tissues by retraction, the tourniquet may be unscrewed a little, so as to admit 
a current of blood, when a jet of the latter will reveal their situation, after 
which the instrument can again be tightened. 
It will be proper, in securing the arteries, to take them in the order of im- 
portance, that is, the largest first, and afterwards those of minor magnitude, 
though the surgeon may deviate from this course when the necessity exists. 
Each vessel should be seized by the tenaculum or by an artery forceps, 
separated as much as possible from all its surrounding connections, and tied 
either with the animal or the silk ligature. If the first, the one which I 
prefer, is used, both ends of the thread should be cut off after making the 
knot. If the silk thread is used, one end only will require to be severed, and 
this close to the knot, the other being left. 
When the surgeon is short of assistants, by using the artery forceps, with 
a catch or a slide, he may tie the vessels without any help, as the weight of 
the instrument, when allowed to hang, will draw the artery sufficiently far 
out for the application of the thread. 
The nerves must be carefully excluded from the ligature. Nor should the 
veins be unnecessarily tied; although I have never seen an ill effect follow 
their inclusion. 
The old mode of carefully isolating the vessels before tying is, I fear, be- 
coming somewhat obsolete, as muscle and fibrous tissue are often raised and 
secured with the vessels,-a practice which, I am confident, complicates the 
subsequent healing, by causing a larger amount of devitalized tissue or sloughs 
in the wound. 
After the ligation of the principal arteries the tourniquet may be loosened, 
in order to ascertain if there remain any vessels requiring to be tied. In 
some instances a general oozing of blood from the stump will occur. This is 
generally venous blood, and its flow depends on the constriction of the tour- 
niquet, and will quickly subside when the pressure of the instrument is 
relaxed. 
Occasionally a free bleeding occurs from the vessels of the medullary tissue 
of the bone, to arrest which a piece of lint may be laid against the end of 
the latter for a short time, in case the oozing should not cease after the 
removal of the tourniquet. 
Nerves.-Any nerves which are seen extending beyond the level of the 
stump must be drawn out and cut off. Otherwise they are liable to become in- 
corporated with the cicatrix, and may give rise to a painful state of the stump. 
Tendons or shreds of muscle which protrude too much require also to be 
retrenched. 
All irregularities or spicula at the end of the bone must be dealt with by 
the cutting pliers. 
Closing the stump.-The stump should not be permanently closed until all 
bleeding, or even oozing of blood, has entirely ceased. Clots, however small 314 
AMPUTATION. 
they may be, remaining in a wound are foreign bodies. They undergo decom- 
position, and thereby not only increase the traumatic fever, but postpone 
quick union by favoring suppuration. 
The practice suggested by Dupuytren, and afterwards inculcated by Liston 
and Syme, of allowing the stump to remain open for a short time, is sound, 
and worthy of a more general imitation. 
As the puncture of the needle is attended with considerable pain, it is 
well to introduce the wire sutures, each three or four inches in length, as 
soon as the ligation of the vessels is over, and to twist their ends loosely 
together. 
If, after the lapse of half an hour or an hour, there are no signs of bleed- 
ing, preparations for closing the stump may be commenced. To do this 
properly it is necessary to consider the condition of the surface of the wound, 
and the changes which it undergoes very soon after the operation. These 
changes result from the mechanical violence and vascular clots. The edge of 
the knife, however keen, being the counterpart of a fine saw, causes number- 
less minute lacerations of the tissues which it divides, so that, if the surface 
of the stump is viewed through a magnifying-glass, it will present a vast num- 
ber of ragged points. (Fig. 1148.) Most of these become sloughs, which soften, 
and, separating from their connection with 
the living tissue, are washed out of the 
wound with the discharges. A vast num- 
ber of minute vessels which do not re- 
quire the ligature are also divided. Their 
canals become plugged with coagula, which 
are sufficient to prevent any bleeding. 
The effect on the circulation of thus les- 
sening the blood-channels is followed by 
an undue vascular fullness, which results 
in a transudation of the liquor sanguinis, 
with numberless cell-forms. It is the 
fibrinous part of this which, adhering to 
the surface of the divided tissues, gives 
to the latter a glazed appearance, while 
the thinner or serous part of the transu- 
dation finds its way out of the wound. 
It is this blood-stained fluid which soaks 
first the dressings of the stump. 
The retention of this fluid, mingled as it must be with fragments of devi- 
talized tissue, is prejudicial in two ways. Entering the vessels, it intensifies the 
traumatic fever; by infiltration and distention of the soft parts, it favors sup- 
puration, and consequently retards the process of repair. For these reasons 
provision must be made to open an unobstructed way for the escape of 
the traumatic discharges. This is best accomplished, first, by avoiding too 
great a redundancy of flap, in which pouches or diverticula are formed, serving 
to collect the sewage of the stump; second, by a dependent position of the 
line of approximation and the use of a drainage-tube. When silk thread 
is employed for tying the arteries, the ligatures serve a good purpose in the 
way of drainage. Third. No more sutures should be introduced than are 
simply sufficient to retain the flaps together. The practice of placing adhe- 
sive plaster across the spaces intermediate to the sutures, or across the wound 
at all, is not only unnecessary, but really harmful, by closing orifices which 
otherwise would give exit to pernicious accumulations. And, lastly, the 
dressing applied over the stump should be such as possesses excellent ab- 
sorbent properties; and, except in cases where the antiseptic plan has been 
adopted, the stump should not be covered with any material that is im- 
pervious to moisture. 
These points settled, we may now proceed to the closure of the stump, 
the drainage-tube having been introduced across the wound with the ends 
Fig. 1148. 
Appearance of a stump after amputation. OPERATION. 
315 
projecting from its angles, along with the ligatures, when other than the 
animal thread is used. 
It is not necessary, however, to bring all the ligatures out of the angles 
of the wound. They may be brought out at other points more convenient 
to their attachments, as they will, by being so distributed, more effectually 
drain away the discharges of the stump. 
The surgeon next twists together the ends of the silver sutures until the 
approximation has been completed. A piece of patent lint, paper lint, or 
old linen, which has been previously treated with a thirty per cent, solution 
of carbolic acid, and afterwards allowed to dry, should now be placed over 
the stump as a cap, covered in with a pledget of soft oakum, and held in po- 
sition by recurrent and circular turns of a roller, which should afterwards 
be continued up the limb to the first articulation, or higher if the muscles 
above require compression. The member is then to be laid in a cradle or a 
sling, to be hereafter described. (Fig. 1149.) 
Instead of elevating the end of the stump, as is frequently done, it should 
be depressed, so as to determine, by gravitation, the discharges from, not to- 
wards, the wTound. 
When the antiseptic method of treatment is adopted, it must be followed 
out according to instructions given in vol. i. page 187. 
While I believe the period of healing is materially shortened by a faithful 
employment of the antiseptic method, yet, by statistics, the comparative 
mortality following the antiseptic and the carefully applied ordinary dressing, 
after amputation, is left unsettled. 
If we compare the practice of six years as conducted in the infirmary at 
Newcastle-on-Tyne,* in which equal periods of time were given to the two 
plans of dressing, the evidence is immensely in favor of the Lister method. 
Ordinary Dressing. 
Year. 
Major Amputations. 
Deaths. 
Mortality, per cent. 
1873 
27 
16 
59.2 
1874 
41 
19 
46.3 
1875 
30 
14 
46.6 
Total 
98 
49 
Antiseptic Dressing. 
Year. 
Major Amputations. 
Deaths. 
Mortality, per cent. 
1876 . 
26 
6 
23 
1877 
32 
5 
15.6 
1878 
50 
2 
4 
Total 
108 
13 
Of 8 amputations done by Barwell at the Charing Cross Hospital,f viz., 
2 of the thigh, 4 of the leg, and 2 of the foot, all dressed antiseptically, there 
were no deaths. 
At the Manchester Royal Infirmary, 35 amputations treated by a modified 
antiseptic plan resulted in 4 deaths and 31 cures, or a death-rate of 11.42 per 
cent. 
31 cases dressed by the Lister details gave 30 recoveries and 1 death. 
Against these results, Mr. gives 44 consecutive amputations 
without antiseptic treatment, with only 1 death. 
In the Pennsylvania Hospital during four years, from 1874 to 1878, 100 
amputations were treated in the ordinary way, with 17 deaths, or a death- 
rate of 17 per cent. 
It would appear, therefore, that until wTe are in possession of a larger num- 
ber of observations, the question of mortality must be held sub judice. 
Maissonneuve, of Paris, adopted a plan of dressing stumps which he termed 
* Lancet, June 8, 1878. f Lancet, March 8, 1878. 
J St. Bartholomew's Hospital Reports for 1874, vol. x. p. 133. 316 
AMPUTATION. 
pneumatic occlusion, the object being to drain away the accumulations from 
the wound by aspiration. For this purpose, a closely-fitting rubber cap, 
having an elastic tube attached to its centre, was placed over the stump. 
The free end of the tube was connected with a glass jar, from which the air 
was occasionally exhausted by an air-pump, thus sucking out and bottling 
up the discharges. The method does not appear to have met with any gen- 
eral favor. Professor Wood, of New York, speaks very favorably of leaving 
the stump without any tight dressings. 
Removal of Dressings.-The first dressing should not be disturbed earlier 
than the third or fourth day, the period for removal being dependent on the 
odor emitted, or on the degree to which the wrappings are soiled. 
In removing the dressings and in applying others, the utmost gentleness and 
care must be observed in handling the limb, so as not to disturb the delicate 
adhesions which have begun in the tissues of the stump; this may be done 
by exciting muscular contractions, or by altering the relations of the soft 
parts by pressure, in either event giving rise to pain. Indifference on this 
point certainly does materially complicate the healing after amputation. 
With a view to insure the desired rest, and to render it practicable to dress 
a limb with the least possible disturbance, I have had constructed a cradle 
(which was suggested by an appliance devised for a similar purpose by 
Mr. Callender, of London), by which a dressing can be removed from the leg 
or the thigh and another substituted without causing the least disturbance 
or pain in the wound. (Fig. 1149.) This cradle or trough is made of per- 
forated galvanized iron, 
and consists of a number 
of segments, connected one 
with another by a hinge, 
and which can be let down 
by drawing back a little 
rod placed on either side 
of the segments, and serv- 
ing to maintain the con- 
tinuity of the trough. 
Hooks are also placed along the upper edge of either side, by which to sus- 
pend the cradle. On this metal trough the limb is laid, after the interposi- 
tion of a little bag filled with sawdust or bran, which forms an easy bed for 
Fig. 1149. 
Cradle for supporting a stump after amputation. 
Fig. 1150. 
the limb, and at the same time soaks up the discharges from the stump, 
(fig. 1150.) The form of this trough causes the end of the stump, when 
Stump supported in a suspended cradle, and one segment dropped previous to dressing. COMPLICATIONS FOLLOWING AMPUTATION. 
317 
suspended, to dip downward, thus preventing the water from running up 
the limb instead of back into the basin, which should be placed underneath, 
during the dressing. 
The arm can be supported in a similar manner. If the stump is not sus- 
pended, it should be placed upon a pillow ovei* which is laid a piece of 
rubber- or oil-cloth, with a towel interposed 
between the latter and the limb. To add to 
the security of the stump, and to guard against 
its being displaced by muscular starts, a strip 
of bandage should be placed across the limb 
and the ends pinned to the pillow beneath. 
(Fig. 1151.) 
After the first renewal of the dressings, it is 
necessary to apply fresh dressings daily as long 
as the discharges from the wound are free. 
Before their application, the stump should 
be thoroughly cleansed with warm water con- 
taining some permanganate of potash. After 
the discharges have in a great measure sub- 
sided, a little oxide of zinc ointment, spread 
on a strip of old linen or lint, may be laid over 
the line of the forming cicatrix. Should no 
complications occur in the progress of the case, the reunion will be completed 
in from eighteen to twenty-one days. 
Structure of Stumps.-The dissection of a stump (Fig. 1152), conducted 
at a time when the ordinary change of tissue has been completed (that is, 
after the lapse of one or two years), reveals a mass 
of fibrous tissue. It matters not how large a cushion 
of muscles or how much adipose matter may have been 
included in the flaps and placed over the ends of the 
bone, it will all have disappeared, leaving only the con- 
nective element which served to unite its fasciculi, 
which, together with that included in the subcutaneous 
tissue and some new formation of the same material, 
constitutes the covering of the stump. The extremities 
of the nerves are somewhat enlarged, and, in many 
instances, bulbous. When the structures of these en- 
largements are unraveled, they are found to consist 
of interlacing fibres of connective tissue, mingled 
with nerve-fibrillae. The vessels which have been tied 
are found obliterated as high as the first collateral 
branch, all below being fibrous cords. The extremi- 
ties of the bones are irregularly rounded, their medul- 
lary canals filled with compact osseous tissue for some 
distance. If a considerable period has elapsed after 
the amputation, the centre of this compact tissue will 
be found somewhat spongy or porous, which indicates 
a tendency to restore both the medullary canal and the 
surrounding cancellated tissue. Occasionally, when there are two bones in 
the stump, as in the forearm oi' the leg, these are connected by a bridge of 
osseous tissue. 
Fig. 1151. 
Stump secured to pillow. 
Fig. 1152. 
Section exhibiting the struc- 
ture of a stump one year after 
an amputation of the arm. 
Complications following Amputation. 
The complications which follow an amputation may be primary or con- 
secutive, local or general. 
Primary Local Complications are hemorrhage, spasm, inflammation, inor- 
dinate suppuration, gangrene, protrusion of the bone, and osteomyelitis of 
the stump. 318 
AMPUTATION. 
Hemorrhage may occur a few hours after the completion of the dressing, 
or it may set in after the lapse of three or four days, and may be arterial or 
venous. When it takes place early, it probably comes from some vessel or 
vessels which have been overlooked during ligation. It may proceed from 
an atheromatous artery, which, in consequence of the brittle state of its 
coats, has broken down under the constriction of the ligature. Or it may 
be the result of a too vigorous reaction, causing the displacement of the clots 
in the small vessels, which, from their size, do not ordinarily demand ligation. 
Or, finally, it may come from the bone. 
When the hemorrhage is venous, it can be distinguished by its dark color, 
and may be caused by the roller being too tight above, instead of compress- 
ing the limb with a uniform pressure. It is not uncommon to find the dress- 
ings, a few hours after an amputation, wet through with a blood-stained watery 
fluid. But this does not require any special interference, as it gradually 
subsides spontaneously. When, however, the dressings are found soaked 
with red or dark blood, the stump should be carefully examined. 
Treatment.-The treatment consists in first elevating the stump. If this 
fails to arrest the flow, the dressings must be removed and others applied, fol- 
lowed by a firmer compression of the stump and limb writh a roller bandage. 
Cold w'atei' and ice may also be placed over the parts. If all this proves un- 
availing, there is no alternative left but to open the stump and seek for the 
offending vessel, whether artery or vein, and apply a ligature. 
When the bleeding comes from the medullary canal, a small compress of 
lint, to which a thread is attached, should be placed against the bone. The 
cord can be brought out through the wound, so that the pledget can be with- 
drawn after two or three days. 
Sometimes the hemorrhage proceeds from one of the vessels in the compact 
tissue of the bone, when it is best controlled by pressing a little beeswax 
into the orifice; or, if this does not answer, by spiking the osseous canal with 
a piece of soft wood sufficiently long to project through the wound when the 
flaps are replaced, so that it can be extracted at pleasure. 
Spasms of the Stump.-In aged persons and those of a nervous, irritable 
temperament there is frequently a painful jerking or twitching of the mus- 
cles of the stump, which is a source of great distress. These spasms may 
involve muscles other than those which have been divided in the amputation. 
Thus, after the removal of the forearm above the wrist, I have seen the 
biceps flexor cubiti more affected than the muscles of the stump itself. 
Treatment.-The judicious application of a roller, by supplying through 
firm pressure what the muscles have lost in tension, will, in most cases, pre- 
vent the development of spasms. Where the latter are more than ordinarily 
severe, after amputation of the forearm, I have found great relief result from 
the application of an anterior or an internal angular splint to the limb. A 
change in the posture of the extremity, such as flexion or elevation, will 
frequently exercise a salutary influence in diminishing the twitchings. 
Should these measures fail, a hypodermic injection of morphia will procure 
the necessary quiet, or the anodyne may be given by the mouth, either with 
or without the addition of the bromide of potassium. 
When the spasm and pain make their appearance two or three days after 
the amputation, a warm flaxseed-meal poultice should be laid over the stump, 
and, in conjunction with the remedies already named, will produce the hap- 
piest effects. 
Inflammation, Suppuration, and Mortification may attack a stump. The in- 
flammation may be common or erysipelatous. This complication does not 
occur earlier than the second or third day, and may appear much later. It 
is frequently excited by imperfect drainage, or it may arise from defective 
hygienic conditions, by which the wound becomes infected through careless- 
ness in the use of dressings or from atmospheric impurities. COMPLICATIONS FOLLOWING AMPUTATION. 
319 
The stump becomes supersensitive, assumes a dusky red appearance, is hot, 
swollen, and tense, the pain being often attended with a burning, throbbing 
sensation. The discharges are scanty, and consist of a bloody serum or an 
ichorous pus. The patient becomes feverish, with a dry tongue and a parched 
mouth, and suffers from a considerable thirst. These symptoms are some- 
times preceded by a chill. Persons of an intemperate habit are peculiarly 
exposed to this complication. 
An attack of this nature may terminate in suppuration at the end of the 
stump, in diffused suppuration, the pus dissecting up the components of the 
limb, or in multiple circumscribed abscesses, and, finally, in mortification of 
the flaps. 
Treatment.-In the management of a case of this nature the stump should 
be carefully examined, to ascertain if there are any vitiated accumulations 
pent up in the wound, and, if so, to open at once a way for their escape by 
cutting one or more sutures and separating with a director the adhesions of 
the flaps at some point. The parts are to be enveloped in hot flaxseed-meal 
poultices, which should be renewed every ten or twelve hours. At the same 
time the pain, restlessness, and febrility must be allayed by the frequent use 
of the neutral mixture containing a small amount of morphia. 
The appearance of healthy suppuration at the wound is quickly followed 
by a subsidence of both the local and the constitutional disturbance, and the 
healing is again resumed. 
When the drift of the disease is asthenic, and the recuperative forces of the 
system begin to flag, it will be necessary to resort to tonic and stimulant rem- 
edies, such as quinine and iron, and to give scrupulous attention to nourish- 
ment. Opium will also prove valuable in securing rest and freedom from pain. 
Abscesses, either of the diffused or of the circumscribed character, must be 
opened as soon as discovered, and these openings should be so planned as 
to contribute in the most effective way to thorough drainage. 
Should the sinuses which sometimes follow these diffused abscesses not 
close by compression or by the injection of a weak solution of the sulphate of 
copper, they may require to be laid open on the director. 
Mortification may attack the flaps of a stump, either in consequence of 
their vitality having been hopelessly impaired by the original injury, or as 
a result of the severe degree of inflammation. In military hospitals, where 
many wounded persons are crowded together, amputations are often followed 
by sloughing. 
Its approach is indicated by a blue or purple discoloration, which gradually 
deepens into black, and is followed by an unpleasant odor. When arising from 
the primary injury, it may not materially affect the general strength unless 
it becomes extensive; but when it follows a destructive inflammation its 
depressing effect on the system is very marked. 
In the management of a sloughing stump, all tension must be removed 
from the flaps, by dividing the sutures. The parts are to be thoroughly 
cleansed by a wash of permanganate of potash, which should be injected into 
every cornei* and crevice of the wound; after which fermenting poultices 
are to be applied, in order to remove any fetor present and to hasten the 
detachment of the dead tissue. The system will at the same time require 
support by a generous diet and by tonics and stimulants. 
Protrusion of Bone is liable to occur from mortification of the soft parts 
covering the bone, and from the retraction of the muscles, especially where 
the flaps have been scant and the roller has been omitted. 
If the exposure is only partial, by the use of adhesive strips with weight 
attached (Fig. 1153), very much after the manner of making extension in 
fractures of the thigh, the integuments may be drawn down sufficiently far 
to repair the evil to some extent; or the remnant of the flaps may be brought 
into sufficient proximity by adhesive strips alone to admit of a cicatrix being 
formed over the bone. But the stump rarely proves satisfactory, being con- 320 
AMPUTATION. 
ical, unduly sensitive, and liable to ulceration. It is from this source that so 
much of the trouble arises in the use of artificial limbs. 
Fig. 1153. 
The only remedy for this defect of the stump is to dissect up the tissues 
and cut off the bone some distance above; or, in bad cases, a formal re-ampu- 
tation will become necessary. 
Extension applied to a scanty flap. 
Secondary Hemorrhage is occasionally met with after amputations, coming 
on at some period between the eighth and fourteenth day, and sometimes 
at a much later interval, after the operation. The flow may be sudden and 
impetuous, or slow and continuous, escaping at one or more places from 
between the flaps. 
The causes of secondary hemorrhage are not always the same. It may 
arise from a premature detachment of the ligature, in consequence of ather- 
omatous alteration in the coats of the vessels, or from sloughing occurring 
before the canals of the arteries have been sealed by an organized tissue. 
The presence of unhealthy pus in a stump has a tendency to soften and 
detach the coagula which close the vessel. And the same changes are 
favored by an unhealthy condition of the blood itself,-such as results from 
hemorrhage, or from a generally depraved state of the fluids. A troublesome 
bleeding may also be caused by enlargement of the vessels and thickening 
of the tissues from inflammatory deposits, incident to necrosis of the bone, 
and on account of which the walls of the vessels become adherent to the 
indurated and inelastic structures, and are thereby kept from contracting on 
their contents. When the bleeding is not copious, the flow maybe restrained 
by pressure applied to the stump and along the course of the main vessel of 
the limb by a compress and roller. If this proves ineffectual, the time for 
temporizing is past. Pressure should be made on the principal artery of the 
extremity at different places, in order to determine the point nearest to the 
stump where the pressure controls the bleeding, and where it will be best 
to expose and ligate the vessel. In the arm and the forearm, where the 
arteries for the most part are very accessible, the acupressure-pin may be 
substituted for ligature. 
In cases where the hemorrhage is dependent on the effect produced on the 
vessels by the indurated tissues around a necrosed bone, preventing their 
contraction and retraction, the removal of the sequestrum will put an end to 
the bleeding. Until this can be accomplished the surgeon must rely on 
circumferential pressure by means of a roller. 
Secondary Complications. 
Osteomyelitis and Necrosis.-The same inflammatory changes which make 
havoc with the soft parts may extend to the bone, attacking the medullary 
tissue, which becomes soft and discolored. The periosteum also separates, 
and the bone dies in its entire thickness. Cases of this nature are not unat- 
tended with danger, from the liability to constitutional infection or pyaemia. 
The necrosis is sometimes attributed to the violence done by the saw in COMPLICATIONS FOLLOWING AMPUTATION. 
321 
disturbing the connections of the periosteum; but I apprehend this is rarely 
the case. When it does not result from inflammatory changes propagated 
from the soft parts, from a deficiency of flap, or from the deleterious contact 
with pus, it is more correctly attributed to the traumatic force which caused 
the injury. The frequency of this affection following amputation on account 
of gunshot wounds inflicted by the conoidal ball tends to corroborate the 
view that post-amputation osteomyelitis is the product of osseous concussion. 
The existence of the necrosis does not entirely defeat the healing of the soft 
parts, though there will remain a sinus over the stump, which continues to 
discharge. At the bottom of this fistulous tract may be discovered denuded 
bone. Nor will the opening close until the sequestrum is removed. The 
separation should be left to nature: it is the work of two, three, or more 
months; and when it is accomplished, the soft parts being separated from the 
sequestrum, the latter must be extracted. This, when pulled away, generally 
appears as a cylinder or ring, including below the entire thickness of the 
bone, and above that portion which forms the circumference of the medullary 
canal. The upper extremity of the sequestrum, being gnawed and spiculated, 
is strikingly in contrast with the lower, which is quite smooth on its surface. 
Conical Stump.-This troublesome condition is the result of insufficient 
flap, of retraction of the muscles, and of sloughing, leaving the bone to be 
covered by granulation tissue. (Fig. 1154.) Stumps of this form are use- 
less for the purpose of support, and are constantly exposed to ulceration, 
as the cicatrix possesses very little vitality. The remedy is re-amputation. 
Bulbous Enlargement of the Bone.-In some instances a profuse outgrowth 
of granulation tissue arises from the medullary structure, and, spreading 
over the cut end of the bone like a cap, is gradually transformed into callus, 
making a nodular mass, which either interferes with the closure of the wound 
or exerts an injurious pressure against the cicatrix. The treatment consists 
in cutting off the bone above the enlargement. 
Neuralgia.-One of the most distressing affections which can befall a 
Fig. 1155. 
Fig. 1154. 
Conical stumps, from a patient in the Pennsylvania 
Hospital. 
Appearance of the nerves of a stump 
after amputation. 
stump is neuralgia. It has both a local and a constitutional origin. When 
dependent on a local cause, it is due to bulbous enlargement, which takes 
place in the cut ends of the nerves of the stump. (Fig. 1155.) This change 
VOL. II.-21 322 
AMPUTATION. 
is the usual one after amputation, and in a large proportion of cases is un- 
attended with any inconvenience. 
These enlargements, which consist of interlacing bundles of connective 
tissue, may undergo hypertrophy, becoming as large as a marble or even a 
walnut; and it is then that they occasion so much suffering. They are more 
generally met with after amputation in the upper extremity. 
The least pressure over these indurated masses is attended with exquisite 
pain. The contraction of the muscles of the stump in the ordinary move- 
ments of the limb is also productive of constant suffering. The disease may 
reside in a single nerve of a stump, or several nerves may be simultaneously 
affected. 
In other cases a nerve becomes incarcerated in the cicatrix of a stump, 
causing a supersensitive condition of the latter. Both conditions are capable 
not only of creating severe pain, but also of exciting violent spasms and 
tremors of the muscles of the limb. 
The treatment proper for these fibrous neuromata is to open the stump and 
excise the diseased bulbs; or, where a number exist, the remedy is re-ampu- 
tation. 
Where the inordinate sensibility is to be referred to a nerve becoming in- 
volved in the cicatrix, the removal of the latter by excision is the course to 
be adopted. 
There is another condition of a stump which is attended with agonizing 
pain, and not unfrequently with a distressing sense of the constant presence 
of the amputated part. The patient dreads the slightest touch of the surface 
of the stump, complains often of the lost toes or fingers being forcibly drawn 
asunder, and is rendered incapable of attending to any business. An exami- 
nation will often fail to discover any tangible evidence of a change in the 
nerves of the sensitive part. These are cases in which the evil is central and 
constitutional, and are rarely benefited by an operation, though, after a long 
time, the disability may wear away. 
A physician in Western Pennsylvania once applied to me for counsel in 
regard to such a condition in his own person. He had, while answering to a 
call during a dark night, ridden into the top of a fallen tree, and, being thrown 
from his horse, bad his elbow so crushed as to necessitate amputation of the 
arm immediately above the elbow. The operation was followed by a painful 
cicatrix, which continued to grow steadily worse until, other measures fail- 
ing, he had submitted to a second amputation. No improvement followed 
the operation, and, in consequence of the unremitting suffering which he ex- 
perienced, he was compelled to abandon all professional work and come to 
Philadelphia for relief. He was desirous of having the remaining portion of 
the arm removed at the shoulder-joint. I dissuaded him from this, and pro- 
posed instead the excision of the axillary plexus of nerves, though at the 
same time speaking very distrustfully of the relief which might be expected 
from such a procedure. The operation, a most tedious and troublesome one, 
however, was done, and, although not followed by entire exemption from 
the old pain, the latter was so greatly modified in its character that the 
patient returned home, was able to resume his professional work, and finally, 
after several months, got entirely well. 
Sometimes the muscular spasms are confined to a single group of muscles, 
when temporary and occasionally permanent relief may be obtained by ex- 
cising a considerable portion of the main trunk of the nerve supplying the 
affected muscles. In a hospital patient who had long been harassed with a 
sense of violent abduction of the foot after an amputation of the lower third 
of the leg, I succeeded in removing this ideal distortion by cutting away a 
portion of the peroneal nerve below the head of the fibula, thus paralyzing 
those muscles whose function it is to produce this particular movement. No 
operation, however, will have any effect in destroying the consciousness of 
the presence of a lost part of a limb, as the sensation is due to psychical and 
not to material conditions. COMPLICATIONS FOLLOWING AMPUTATION. 
323 
In that neuralgic condition of a stump which comes on independent of 
any discoverable nerve-lesion, and which is often influenced by atmospheric 
changes, and also by mental and physical excitement, constitutional remedies 
alone are to be employed, such as quinine and arsenic in full doses. If there 
are signs of antemia, iron will also be indicated; and when the pain is excess- 
ive, the hypodermic use of morphia will give temporary relief. These cases 
are frequently not amenable to treatment. 
Contraction of Tendons.-In amputations below the knee, where the leg has 
long been allowed to remain flexed, the hamstring muscles may become so 
shortened as to offer great resistance when an attempt is made to straighten 
the stump. 
The difficulty is usually overcome bv repeated efforts at extension of the 
leg. 
The same difficulty may occur at the elbow, by long contraction of the 
biceps muscle, and is to be treated in a similar way. 
After the amputation known as Chopart's, the heel may be drawn up by 
the action of the tendo Achillis so as to bring the foot into a position which 
will expose the cicatrix to pressure. Tenotomy and a properly-adjusted 
splint constitute the appropriate means for correcting this evil. 
Aneurismal Varix.-This very rare condition I have only once witnessed. 
The subject was a negro boy, whose thigh had been amputated at the lower 
third five years previous. A connection had formed between the femoral 
artery and the femoral vein at the extremity of the stump, most probably 
due to both vessels having been included in the same ligature at the time of the 
operation. All the veins of the limb were distended, varicose, and pulsated 
strongly, yielding the peculiar sound which belongs to this form of aneurism. 
Mr. Cadge, of Norwich, England, has recorded a similar condition affecting 
the posterior tibial arteries and veins of the leg after an amputation at the 
ankle-joint. 
Cases of this nature are not proper subjects for surgical interference, and 
do not specially endanger the life of the patient. 
Degeneration of the Tissues of a Stump.-The structures immediately 
related to a stump gradually undergo fatty and fibrous transformations. 
The fatty degeneration is one very commonly connected with diseases or 
injuries involving the bones. Thus, in cases of necrosis, the overlying mus- 
cles are found to be largely replaced by fat, though they may still retain their 
form and measurably their size, the adipose material having displaced the 
sarcous substance, leaving only the connective tissue of the muscle, and giving 
to the latter a yellow appearance. The same change occurs in the tissues of 
a stump. 
The fibroid hypertrophy, in which there is a large increase of the connective 
tissue of a stump, is attended with undue sensibility of the parts, and is an 
inflammatory product, caused by undue pressure, generally from a badly- 
fitting artificial limb. It may be accompanied by obstinate ulceration, 
rendering it necessary, in some cases, to open the stump, remove the indu- 
rated tissue, and retrench the bones. 
Malignant degeneration.-After amputation for cancer, the disease may 
reappear in the tissues of the stump. Such an occurrence is an expression 
of a widely-disseminated vice, and gives no encouragement to repeat the 
operation. 
Bursa.-Continuous pressure on the end of a stump may be instrumental 
in producing a bursal sac, which can be readily recognized as a slightly 
fluctuating swelling, over which the skin presents a wrinkled or rugose 
appearance. This sac is liable to become inflamed and to cause serious 
inconvenience to the patient. 324 
AMPUTATION. 
The remedy is to relieve the end of the stump from all pressure. The 
stimulus being removed, the bursa will spontaneously disappear. It would 
be an aggravated case which would justify excision. 
Simultaneous Amputations. 
The necessity for the removal of two or more limbs will occasionally arise 
as a result of railroad and other accidents, and, with few exceptions, it is 
better that the operations should be executed simultaneously. 
The morale of the patient is better at the primary than at any other period; 
and as far as my own observation extends, which is limited to five cases, 
the shock succeeding the double amputations did not appear to be materially 
greater than w'hat would have attended a single one. 
The surgeon, however, in such emergencies must be guided in his course 
by the condition of the patient. It would obviously be improper to remove 
two limbs at the same time if the person was greatly depressed at the time 
of operation or should exhibit serious signs of exhaustion after one amputa- 
tion. In either case the second operation should be delayed until the effects 
of the shock have in a great measure disappeared, which may be sufficiently 
early to bring it within the primary period. If this does not occur, it will be 
best to defer action until after the inflammatory or intermediary period has 
passed. 
Where double amputations are demanded in consequence of injury to 
different parts of the extremities,-as the thigh of one and the leg of the other, 
-and there is a doubt in the surgeon's mind as to the patient's ability to 
endure synchronous operations, it will be best to select for the first amputa- 
tion the part of greatest magnitude, so that the consecutive operation shall 
inflict the least shock possible. 
Even triple synchronous amputations have been done with entire success, 
in one instance by Dr. Koehler, of Schuylkill Haven, Pennsylvania, and in 
another by Dr. Stone the elder, of New Orleans. In the town of York, Penn- 
sylvania, in 1868, the right thigh and left leg and the right forearm and three 
fingers of the left band were successfully removed from a patient at one 
operation. 
When synchronous amputations are performed, the two limbs should be 
removed in quick succession, the surgeon not stopping to tie any vessels until 
both have been cut off; or the vessels of one limb may be secured by an 
assistant while the other is being removed. 
More than usual care, under these circumstances, must be observed in 
adjusting the tourniquet so as to control the circulation and prevent as far as 
possible the loss of blood. The elastic bandage of Esmarch can be used with 
advantage in cases of this nature; or in amputations of both lower extremi- 
ties the circulation can be completely arrested by the application of the 
abdominal tourniquet. 
If two surgeons are present, the operations may be strictly simulta- 
neous, by each taking a limb,-a plan which has the advantage of diminish- 
ing the time consumed in the amputation, and, consequently, of lessening 
the shock. 
Of 74 cases of multiple amputation performed after recent injury, collected 
by Dr. Baum from the sources indicated, and tabulated on the following 
pages, 36 died and 38 recovered. 
In three cases performed by myself, all were successful. SIMULTANEO US AMPUTA TIDES. 
325 
Simultaneous Multiple Primary Amputations. 
Source of Information. 
Parts amputated. 
rd 
3 
Cured. 
Remarks. 
Guy's Hospital Reports, Series III., vol. xv. p. 
630. From 1861-68 (inclusive) 
Legs 
2 
1 
From 1869-78 (inclusive): 
Thigh and leg 
Leg and arm 
3 
2 
Vol. xvi. p. 571 
Thighs 
1 
Vol. xvii. p. 520 
Legs and hand 
1 
Vol. xix. p. 535 
Knee-joint and thigh 
1 
Vol. xx. p. 556 
Right hip and left Uiigh 
1 
Vol. xx. p. 556 
Legs (three cases) 
3 
Vol. xx. p. 556 
Forearms 
1 
Vol. xxi. p. 446 
Legs 
1 
Vol. xxi. p. 446 
Thigh and forearm 
1 
Vol. xxii. p. 490 
Ankle-joints 
1 
St. Thomas's Hospital Reports, 1870-77 (inclu- 
sive): 
Vol. i. p. 676 
Feet 
1 
Vol. iv. p. 318 
Legs 
1 
Vol. v. p. 434 
Left hip and right ankle 
1 
Vol. vi. p. 354 
Legs 
1 
Vol. vii. p. 372 
Three cases (parts not stated).... 
1 
2 
Vol. viii. p. 645 
Legs 
1 
St. George's Hospital Reports, 1865-76 (inclu- 
sive) : 
Vol. i. p. 426 
Legs 
1 
Vol. iii. p. 370 
Arms 
1 
Vol. iv. p. 341 
Legs 
1 
Vol. v. p. 310 
Thighs 
1 
Vol. vi. p. 368 
Legs 
1 
Vol. vii. p. 298 
Thighs 
1 
Vol. vii. p. 300 
Thigh and forearm 
1 
Vol. viii. p. 487 
Legs 
1 
Vol. viii. p. 487 
Thighs 
1 
Vol. viii. p. 489 
Wrists 
1 
Vol. viii. p. 490 
Thighs (died on table) 
1 
St. Bartholomew's Hospital Reports, Appen- 
Vol. xii. p. 70 
Legs 
1 
Vol. xii. p. 70 
London Lancet, 1860-78 (inclusive): 
Arms 
1 
Vol. ii., 1868, p. 185 
Right thigh and left leg 
1 
Vol. L, 1869, p. 878 
Legs 
1 
Vol. ii., 1872, p. 814 
Legs 
1 
Vol. L, 1873, p. 629 
Left leg and right arm 
1 
Vol. L, 1873, p. 629 
Thighs (middle and supra con- 
Liverpool Medical and Surgical Reports, 1867- 
dyloid) 
1 
71 (inclusive): 
Vol. i. p. 87 
Thighs (at middle third) 
1 
Vol. iv. p. 158 
Legs 
1 
Vol. v. p. 120 
Legs 
1 
United with Manches- 
Liverpool and Manchester Medical and Sur- 
ter in 1872. 
gical Reports, vol. v. p. 243 
Medical Times and Gazette, 1860-78 (inclu- 
Arms 
1 
sive), vol. L, 1876 
Right arm and left tarsus 
1 
Thighs 
1 
Left arm and leg and anterior 
Harrisburg Hospital, 1874-79 (inclusive) 
half of right foot 
Thigh and leg 
1 
1 
Thos. J. Dunott, M.D., 
Legs 
1 
operator. 
During 1874, at Johnstown, Pa 
Thighs 
1 
Legs 
1 
W. B. Lowman, M.D., 
New York Medical Record, vol. viii. p. 281, 
operator. 
1866-79 (inclusive) 
American Journal of the Medical Sciences, vol. 
Leg and foot 
1 
xliii. p. 537 
Forearms 
1 
Taken from Glasgow 
Hospital Gazette and Archives of Clinical Sur- 
Med. Jour., Jan. 1862. 
gery,1878 
One case 
1 
Medical and Surgical Reporter, vol. xxv. p. 60, 
1860-78 (inclusive) 
Thighs and right forearm 
1 
Dr. Harten, of Horde, 
Germany, operator. 
At York, Pa., 1868 
Right thigh and left leg; right 
forearm and three fingers of 
Medical Times and Gazette, 1861, April 20, p. 
left hand 
1 
416 and p. 493 
Right forearm and left hand 
1 
Right knee-joint and left leg, 
one inch below knee.... 
1 
Right leg and left toes 
1 
Legs 
1 326 
AMPUTATION. 
Simultaneous Multiple Primary Amputations.-{Continued.) 
Source of Information. 
Parts amputated. 
■8 
2 
Cured. 
Remarks. 
Surgical Reports and Miscellaneous Papers, 
by George Hayward, M.D., from cases at 
Massachusetts General Hospital, p; 148 and 
p. 157; also, American Journal of the Med- 
ical Sciences, vol. xxvi. p. 66 
Legs 
1 
Forearm and arm 
1 
Thigh and leg 
1 
American Journal of the Medical Sciences, 
July, 1854, p. 14, vol. xxviii. Notes from 
Pennsylvania Hospital Statistics 
Legs 
1 
1 
Feet 
1 
Amer. Jour. Med. Sci., 1875, vol. Ixix. p. 319... 
Verbal report 
One case (parts not stated) 
1 
Hip-joint and lower third of leg 
1 
Dr. John Ashhurst, 
- 
operator. 
36 
38 
Re-amputation may be necessitated by a badly-formed or a diseased 
stump. For example, the flaps may slough or become retracted so as to 
expose the bone. The bone itself may be the subject of disease, as of ne- 
crosis or osteomyelitis, or the nerves of the stump may become so exceed- 
ingly painful from an enlarged state of their extremities as to require a 
second amputation. 
The rules to be observed in re-amputation are such as have reference to 
time and place. 
The proper time is when the patient's general strength is sufficiently estab- 
lished for him to undergo the operation, and when the soft parts are in a 
healthy state. 
The place must be determined by local conditions, always selecting a point 
which will secure a sufficient covering for the bones. 
When the bones are necrosed or affected with osteomyelitis, the flaps 
must be formed with a view to exploration, and the section made in sound 
osseous tissue. 
In osteomyelitis it is often difficult to determine the limits of the dis- 
ease, especially after gunshot injuries inflicted by the conoidal ball, in which 
the concussion is widely felt through the fibres of the bone. If upon ex- 
amination, therefore, the disease is found to be very neai* to an articula- 
tion, the most prudent course will be to amputate in the continuity of the 
limb or at the contiguous joint. 
Intra-Uterine Amputations. 
These are such as occasionally occur in the foetus, produced most probably 
through the agency of bands of lymph, as pointed out by Montgomery.* 
These bands, when encircling a limb, gradually, by their contraction, effect 
its amputation. . The writer just named found in a foetus of five months a 
complete ligation around each band, causing a distinct groove where it passed ; 
the parts below were imperfectly developed. Similar bands encircling each 
ankle had divided two-thirds of their thickness, but without any lesion of 
the skin. 
Mr. Watkinson met with a case in which the left foot, above the ankle, had 
been amputated by the same process. 
M. Chaussier has described three cases, two of the forearm and one of the 
arm and hand. In the latter the amputated part was lying in the membranes, 
and the stump had healed. 
A specimen of this amputation is mentioned in Leishman's Midwifery as 
being in the possession of the Obstetric Museum at the University of Edin- 
* Dublin Journal of Medical and Chemical Sciences, vol. i., 1839. ARTIFICIAL LIMBS. 
327 
burgh. The separated portion was the left forearm. The subjoined table 
contains seven cases of similar amputations. 
Spontaneous Amputations in Utero. 
Source. 
Part amputated. 
No. 
Reporter. 
New York Medical Record : 
Vol. i. p. 27 
Vol. v. p. 420 
Vol. v. p. 420 
Med. and Surg. Reporter, vol. 
xxxiii. p. 217 
Boston Med. and Surg. Journ., 
New Series, vol. iii. p. 409... 
Vol. iv. p. 81 
Right leg, 4 inches below knee, 
with constriction of thigh, 4j 
inches above knee 
Right arm, J inch below elbow. 
Right arm, at junction of upper 
and middle thirds 
Just below insertion of biceps, on 
left forearm 
At left metacarpus 
Finger, at metacarpo-phalangeal 
joint 
Right arm and left forearm 
1 
1 
1 
1 
1 
1 
1 
7 
Oscar H. Young, M.D. 
George Pepper, M.D. 
J. F. Wilson, M.D. 
Dr. Macau. 
Dr. Paul Munde, Bavaria. 
Mr. Ed. Cheatte, Edinburgh. 
Dr. Little, reported verbally. 
Artificial Limbs. 
The time when an artificial limb may be worn after an amputation is a 
point in respect to which surgeons differ. The condition of the stump must, 
of course, in a great measure, determine the period when it will be advisable 
to adjust such an appliance. Neither the presence of an ample covering 
nor the completion of the cicatrization of the stump is evidence of the fit- 
ness of the parts to endure to the best advantage the pressure necessarily 
connected with wearing an artificial limb. The cicatricial tissue continues 
to condense and to become more compact with the lapse of time. It also 
becomes more loosely connected with the subjacent parts, so as to move with 
greater freedom over the surface of the stump. As these changes require 
time for their perfection, it is rarely the case, in my judgment, that a limb is 
ready to receive any prosthetic mechanism earlier than three months after 
the healing. 
It is only to the lower extremity that an artificial limb can be adjusted so as 
to have any practical value. Those limbs which are designed for the upper 
extremity answer very well for purposes of parade or appearance, but as 
a means of prehension are almost worthless. 
For the lower extremity there are two kinds of mechanism worn,-the old 
peg (Fig. 1156) and the more modern and elegant hollow appliance, fash- 
ioned out of willow wood, having the figure of the natural limb, and with 
joints and cords designed to imitate the movements of the articulations and 
the actions of the muscles. The limbs of Palmer, of Kolbe, and of Osborne, 
Philadelphia manufacturers (Fig. 1157), in point of lightness, strength, elegance 
of construction, and utility, are entitled to special notice. 
These hollow artificial limbs are constructed so as to receive the natural 
limb on the same principle as that by which a tooth rests in the socket of 
the alveolus, the pressure being distributed over the periphery of the leg or 
thigh, as the case may be, and not on the end of the stump. On this account 
accuracy of fit becomes a prime object; and this can be attained in no other 
way than by first taking a plaster cast of the extremity and constructing 
the artificial limb from the mould. The application of this principle, though 
it is absolutely necessary, is attended with one drawback, which appears 
to be unavoidable, namely, shrinkage or wasting of the limb, which is the 
result partly of pressure and partly of disuse of the muscles. In conse- 
quence of this change the socket after a time becomes too large for the 328 
AM PUT A TION. 
extremity, and requires to be changed for a smaller one, or to be filled 
in so as to conform to the receding soft parts. 
The value of an artificial limb must, 
in general, be measured by the length 
of the stump; for by increasing the 
length of the lever the power and use- 
fulness of the limb will be enhanced. 
The exception to this rule prevails in 
amputations above the ankle, where it 
is better, in order that the stump may 
have a regularly increasing size, that 
the operation should be performed 
three inches above the malleoli, rather 
than at the lowest point, where it 
w'ould be larger than immediately 
above. 
When the choice of amputation lies 
between the knee and the lower third 
of the femur, there must be no de- 
parture from the general rules. The 
mechanical argument must yield to 
the superior consideration of safety to 
life ; and, consequently, the amputation 
should be done through the joint rather 
than above it. The knee, moreover, on account of the dense organization 
of the skin, and also the great extent of surface, endures pressure better than 
any other part of the limb. 
After disarticulation at the hip-joint, it is possible to wear an artificial limb 
with advantage. For the natural extremity in such cases is substituted, for 
eight or ten inches, a gutta-percha stump, secured by a broad girdle buckled 
round the pelvis. (See hip-joint amputation.) 
Amputations through the foot, such as are commonly known by the names 
of Lisfranc, Ch op art, Pirogoff, and Syme, re- 
quire an ordinary boot, in which the lost part 
of the foot is supplied by soft wood or cork, 
the end of the stump generally enduring the 
pressure of the superincumbent weight of the 
body very well. Prosthetic appliances de- 
signed for special cases are represented under 
the head of the different amputations. 
The simplest and, for laboring persons, the 
most useful artificial appliance after amputa- 
tions below the forearm is a leather sheath (to 
receive the stump and the arm), at the end of which is a plate with a hook. 
The sheath is connected with a leathern girdle, above the elbow, by steel 
bars having an articulation answering to the joint. (Fig. 1158.) 
Fig. 1156. 
Fig. 1157. 
Peg leg. 
Artificial leg. 
Fig. 1158. 
Simple artificial mechanism for the 
forearm. 
STATISTICS OF AMPUTATION. 
The following tables, compiled from the reports of various civil hospitals 
in this country and abroad, will serve to elucidate some points of interest 
connected with this subject. 
In Table I. are collected 14,366 cases of amputation, all of which, except 
62. may be regarded as major operations. 9415 of this number recovered and 
4951 died, showing an average death-rate of 34.46 per cent., or 1 in every 
3 patients operated on. 
This is a startling statement, but no doubt is entirely correct, as it cor- 
responds to the conclusions reached by Mr. Lane and Mr. Phillips, having 
the advantage, moreover, of being based on far more extended data than 
those used by the gentlemen just named. STATISTICS OF AMPUTATION. 
329 
I. 
Table of Amputations for all Causes and at all Periods; showing also the Average 
Mortality for Different Amputations, and also for Amputations of all Kinds. 
Seat. 
No. of Cases. 
Cured. 
Deaths. 
Death-Bate. 
Hand 
62 
56 
6 
9.67 
Wrist-joint 
115 
112 
3 
2.60 
Forearm 
1,313 
1,120 
193 
14.69 
Elbow-joint 
30 
28 
2 
6.66 
Arm 
2,867 
2,190 
677 
23.61 
Shoulder 
298 
178 
120 
40.13 
Foot 
159 
130 
29 
18.23 
Ankle-joint 
150 
126 
24 
16.00 
Leg 
4,337 
3,018 
1,319 
30.41 
Knee-joint 
215 
119 
96 
44.65 
Thigh 
3,947 
2,018 
1,929 
48.87 
Hip-joint 
836 
305 
531 
63.51 
Double 
37 
15 
22 
59.45 
Aggregate 
14,366 
9,415 
4,951 
34.46 
In Table II. there is collected a total of 5956 amputations, classified in such 
a manner as to show the results of such operations when performed for in- 
jury and for disease, and also for primary and secondary amputations, under 
each general heading. 
For injury there are 3353 amputations. Of this number, 1313 died and 
2040 recovered,-a mortality of 39.16 per cent. For disease there are re- 
corded 2603 amputations, with 618 deaths and 1985 cures,-a mortality 
of 23.74 per cent.; showing 15.42 per cent, in favor of amputations performed 
for disease. 
Considering next the subjects of primary and secondary operations, there 
were 3353 amputations executed for injury; 2572 being done during the pri- 
mary period, with a death-rate of 35.81 per cent., and 781 being performed in 
the secondary period, with a mortality of 50.19 per cent.; showing 14.38 per 
cent, in favor of primary amputations. 
Table of Amputations with Reference to Cause and Period of Operation. 
II. 
Seat. 
INJURY. 
DISEASE. 
PS 
2 
£ 
s 
S 
o 
*3 
© 
5 
£ 
© 
P 
ft 
ft 
o 
o 
ft 
■8 
73 
© 
2 
© 
cS 
© 
P 
K 
QQ 
◄ 
w 
2 
P 
s 
"© 
3 
o 
*© 
p 
© 
"ft 
© 
P 
3 
o 
E- 
75 
© 
P 
<© 
£ 
© 
P 
Hand 
Wrist-joint 
Forearm 
Elbow-joint 
Arm 
Shoulder 
Foot 
Ankle-joint 
Leg 
Knee-joint 
Thigh 
Hip-joint 
Double 
Aggregate... 
49 
69 
430 
5 
546 
42 
69 
19 
736 
49 
513 
13 
32 
46 
69 
384 
5 
391 
21 
52 
11 
396 
34 
228 
2 
12 
3 
46 
155 
21 
17 
8 
340 
15 
285 
11 
20 
6.12 
10.69 
21.00 
50.00 
32.69 
42.10 
46.19 
30.61 
55.55 
84.61 
62.50 
6 
2 
89 
1 
133 
6 
13 
9 
269 
14 
230 
5 
4 
2 
69 
3 
9 
8 
131 
6 
85 
2 
2 
2 
22 
64 
1 
1 
138 
8 
145 
3 
2 
33.33 
24.94 
48.12 
50.00 
30.76 
11.11 
51.30 
57.34 
63.04 
60.00 
50.00 
7 
8 
181 
5 
207 
13 
76 
47 
691 
35 
1142 
190 
1 
6 
7 
164 
4 
171 
10 
69 
41 
555 
26 
829 
102 
1 
1 
1 
17 
1 
36 
3 
7 
6 
136 
9 
313 
88 
14.28 
12.33 
9.39 
20.00 
12.56 
23.07 
9.21 
14.93 
19.10 
25.74 
27.40 
46.31 
62 
79 
700 
11 
886 
61 
158 
75 
1696 
98 
1885 
208 
37 
6 
1 
85 
1 
255 
27 
28 
15 
614 
32 
743 
102 
22 
9.67 
1.26 
12.01 
9.09 
28.75 
44.26 
48.27 
20.00 
36.25 
32.64 
39.40 
49.03 
59.45 
2572 
1651 
921 
35.81 
781 
389 
392 
50.19 
2603 
1985 
618 
23.74 
5956 
1931 
32.42 330 
AMPUTATION. 
Table III., letter a, embraces a collection of 4204 major amputations, gath- 
ered from the records of sixteen different hospitals in America, Great Britain, 
and on the Continent, 1290 proving fatal,-a death-rate of 30.68 per cent. 
Letter b, same table, exhibits the mortality for all amputations in a num- 
ber of prominent hospitals, the aggregate collection of cases amounting to 
5473, with 1899 deaths, or a mortality of 34.69 per cent. 
III. 
Table of Mortality of Amputations. 
(a) Mortality of Mayor Amputations. 
Where performed. 
No. of Cases. 
Deaths. 
Death-Rate. 
Bellevue and Charity Hospital 
55 
19 
34.54 
Birmingham Hospital... 
33 
8 
24.24 
Boston City Hospital 
366 
145 
39.61 
Edinburgh Royal Infirmary 
26 
11 
42.30 
Guy's Hospital 
581 
206 
35.45 
Hotel-Dieu de Rouen 
47 
9 
19.15 
Leeds General Infirmary . 
189 
45 
23.80 
London Hospital 
132 
73 
55.31 
London and provincial hospitals (thigh and leg) 
640 
205 
32.06 
Massachusetts General Hospital 
784 
193 
24.61 
Pennsylvania Hospital 
712 
197 
27.66 
Radcliffe Infirmary (Oxford) 
46 
5 
10.86 
St. Bartholomew's Hospital 
97 
14 
14.43 
St. George's Hospital 
180 
74 
41.11 
St. Thomas's Hospital 
181 
61 
33.64 
Various places in England 
135 
25 
19.25 
Total 
4204 
1290 
30.68 
(&) Mortality of all Amputations. 
Boston City Hospital 
135 
56 
41.44 
Glasgow Royal Infirmary 
1973 
672 
34.10 
Guv's Hospital 
735 
253 
34.42 
Paris hospitals 
1144 
522 
45.60 
Pennsylvania Hospital 
902 
230 
25.49 
St. Bartholomew's Hospital 
358 
* 74 
20.67 
St. George's Hospital 
226 
92 
40.70 
Total 
5473 
1899 
34.69 
These figures exhibit a greater death-rate by 4 per cent, for amputations 
of all kinds than for those usually designated as major amputations,-an 
apparent anomaly which is explained by the high mortality attending 
operations on the foot, which is 4 per cent, greater than that attending 
operations done on the hand. 
Table IV., containing 3521 major amputations, is arranged with a view to 
compare the mortality in American, London, and Parisian hospitals, the 
mortality being 28.81 per cent, in American, 36.70 per cent, in London, and 
56.54 per cent, in Parisian hospitals. STATISTICS OF AMPUTATION. 
331 
IV. 
Table of Comparative Mortality of Major Amputations in American, London, 
and Paris Hospitals. 
Seat. 
American. 
London. 
Paris. 
No. of 
Cases. 
Deaths. 
Death- 
Rate. 
No. of 
Cases. 
Deaths. 
Death- 
Rate. 
No. of 
Cases. 
Deaths. 
Death- 
Rate. 
Thigh 
560 
201 
35.89 
535 
224 
41.86 
199 
126 
63.31 
Leg 
711 
224 
31.50 
345 
136 
36.52 
191 
105 
54.97 
Arm 
306 
74 
24.18 
173 
53 
30.63 
91 
41 
46.15 
Forearm 
297 
41 
13.80 
113 
15 
12.30 
Total 
1874 
540 
28.81 
1166 
428 
36.70 
481 
272 
56.54 
The American hospitals compared in the above table are the Pennsylvania 
Hospital, Bellevue and Charity, Boston City, and Massachusetts General; 
the London hospitals are Guy's, St. Bartholomew's, St. George's, St. Thomas's, 
and the London Hospital; the Paris table is furnished from Malgaigne's 
summary. 
In Table V. a comparison is drawn between the results of amputations in 
four large hospitals for-with the exception of one (Guy's)-approximately 
a like number of years and a like number of cases. 
V. 
Hospital. 
Period of Time. 
No. of Cases. 
Death-Rate. 
Pennsylvania Hospital 
From 1870 to 1878 
252 
21.43 
St. Thomas's Hospital 
" 1869 to 1877 
252 
30.95 
St. George's Hospital 
" 1865 to 1876 
230 
41.30 
Guy's Hospital 
" 1861 to 1878 
742 
35.71 
Table of Mortality of all Amputations in Recent Years. 
From 1874 to 1878 the whole number of amputations at the Pennsylvania 
Hospital was 100, with 17 deaths, or a mortality of 17 per cent. 
In a grand summary of amputations at the Pennsylvania Hospital from 
January 1, 1831, to January 1, 1875, there were 902 amputations upon 896 
patients; of whom 663 were cured, 230 died, or 25 per cent., and 3 were removed 
by friends. 618 were primary; 460 cured, 155 died, or 25 per cent. 95 were 
secondary; 55 cured, 40 died, or 42 per cent. 185 were chronic; 148 cured, 
35 died, or 19 per cent. 
Of the 230 deaths, 59 occurred within 5 days after the amputation, 32 
occurred between 5 and 10 days, 139 occurred after 10 days. 
Of the total number of deaths after amputations during 45 years, we find 
that the mortality of the different months of these years was as follows: in 
January, 11 died; February, 15; March, 15; April, 16; May, 27; June, 25; 
July, 29; August, 22; September, 19; October, 21; November, 11; De- 
cember, 19. 
Analyzing the 902 amputation's, we find the mortality and general results 
as follows: 332 
A MP UTA TION. 
1 
Hip 
Thigh 
Knee 
Leg..... 
Foot 
Shoulder 
Arm 
Forearm 
Elbow 
Wrist and hand 
Primary. 
Injury. 
4- CO ►-* CO t-1 tO ; 
Cured. 
; ; IO >-* -J to 
: : to c ~4 o to oo ci t-1 
Died. 
: • >-* co to co co ci o 
: : 
Per cent. 
h* : 
Secondary. 
r-*: c to ci h h to 
Cured. 
: : c* -4: i-15 »-* -j co j Died. 
: : 8SS: ggggg Percent. 
. >-< _1 t-i o cn • 
co: 00 1-* Ci co -4 -4 . 
Disease. 
: >-* -1 cn ; 
co: -4 CD Ci to CO O r-* • 
Cured. 
• : to: *-* •-* co: 
Died. 
: : to oo : oo S X : Per cent. 
Cl O CO to O CD CO to 
b0C0O"40iCiF-'C0t-*O 
No. 
Total. 
. . K-i K) nJ C *-* 
: : co cd -uo c> o ci 4* 
Died. 
. . f-itotoMcecccoo 
: : f-1 f-1 cc oc o p "4 p 
: ; to f-* rfx w h c> 
• : 4- ci oc C5 
Per cent. 
Causes of mortality after amputation.-Age exerts a marked determining 
influence on the mortality of amputations. Of 881 patients who have un- 
dergone amputations in the Pennsylvania Hospital, and whose ages have been 
recorded, 288 were under 20 years, of whom 246 were cured, and 142 died, 
or 15 per cent.; 259 were between 20 and 30 years, of whom 193 were cured, 
and 66 died, or 25 per cent.; 176 were between 30 and 40 years, of whom 
124 were cured, and 52 died, or 30 per cent.; 105 were between 40 and 50 
years, of whom 71 were cured, and 34 died, or 32 per cent.; 53 were upwards 
of 50 years, of whom 28 were cured, and 25 died, or 47 per cent. 
The measure of vitality, and the capacity to resist those influences which 
tend to destroy life, appear, therefore, to diminish steadily from youth up- 
ward. The statistics of Holmes, Callender, and Bryant all go to confirm this 
conclusion. 
The fatality resulting from shock varies in different hospitals. There are 
some institutions which, from their location, contiguous, for example, to a 
great railroad centre, receive a class of accidents which, from the manner in 
which they are produced, are likely to be accompanied by severe bodily 
injury, and where a fatal termination must necessarily follow, altogether inde- 
pendent of the amputation they often require. In the large collection of 
statistical data that have been tabulated, it has been found impossible in a 
great many instances to ascertain the cause of death, but, so far as this could 
be done, a little over 32 per cent, of all fatal cases were found to have 
perished from causes directly and only referable to the injury, as hemor- 
rhage, shock, etc. 
About 32 per cent, of fatal cases are to be placed to the credit of pyae- 
mia. Secondary amputations suffer very much less from this cause than 
primary. I have been struck with the small number of deaths from hemor- 
rhage, which, so far as I can determine from the statistics of amputation in 
the Pennsylvania Hospital, does not exceed 7 per cent. Mr. Bryant also 
estimates the fatal cases from this cause at 7 per cent. Besides the causes 
already mentioned, a few of the deaths following amputation are to be re- 
ferred to tetanus, or to disease of the kidneys or other internal organs. 
Table showing, from 444 Fatal Cases of Amputation, the Percentages of Deaths 
referred to Chief Causes. 
Shock, 
Collapse, 
and Ex- 
haustion. 
Pyaemia 
and Sep- 
ticremia. 
Secondary 
and Re- 
current 
Hemor- 
rhage and 
Gangrene. 
Erysip- 
elas. 
Tetanus. 
Visceral 
Complica- 
tions. 
Bron- 
chitis and 
Asthma. 
Delirium. 
Primary 
18.5 
10.5 
2.6 
0.7 
0.6 
1.7 
0.3 
0.6 
Secondary 
5.2 
9.3 
2.6 
0.0 
1.9 
0.1 
... 
Disease 
10.6 
12.6 
2.4 
0.8 
0.5 
6.4 
0.3 
0.3 
Total 
34.3 
32.4 
7.6 
1.5 
3.0 
8.2 
0.6 
0.9 AMPUTATIONS IN THE UPPER EXTREMITY. 
333 
The question which naturally arises from this analysis of the causes of 
death after amputation is one entitled to the most serious consideration, 
Can this mortality be diminished1? The solution of this subject does not rest 
alone with the surgical staff of a hospital, but devolves with greater force 
on the management. The history of many of the German hospitals, and 
the experience in the Pennsylvania Hospital during the last few years, suf- 
ficiently demonstrate the feasibility of almost entirely eliminating pyaemia 
from the causes of death after amputation, and thereby saving, approxi- 
mately at least, 32 per cent, of human life. Can a more cogent motive be 
presented for the introduction into our hospitals of every known improve- 
ment in ventilation and surgical dressings? 
All amputations are done either in the continuity or in the contiguity of 
a limb. In speaking of special or individual amputations, I shall describe 
first those which are practiced in the upper extremity, beginning in each case 
with the distal portion of the limb. 
Special Amputations. 
AMPUTATIONS IN THE UPPER EXTREMITY. 
Amputations of the Phalanges.-The ungual phalanges, though frequently 
the subjects both of disease and of injury, rarely require a formal amputation. 
When, in consequence of necrosis or crush, it becomes necessary to remove 
the bone, the operation should be confined to enucleating the phalanx, leaving 
the soft parts and the nail, which, though they may become somewhat mis- 
shapen, serve to prolong the finger and, in a great measure, to preserve its 
natural appearance. 
When it is necessary to amputate as high as the intermediary phalanx, it 
is better to operate at the metacarpo-phalangeal articulation ; for the subse- 
quent approximation of the adjoining fingers will have scarcely any deform- 
ity, whereas if the first phalanx be allowed to remain, the stump becomes 
a very conspicuous and unsightly feature, and does not materially add to 
either the strength or the usefulness of the hand. 
The exception which is made to this rule is in the case of the index finger, 
the smallest portion of which, in certain occupations, is of indispensable im- 
portance. 
No part of the thumb should be sacrificed when its preservation is possible. 
The loss of this member, from its functional importance, is a serious calamity 
to the hand. 
When the cause which necessitates the amputation of a phalanx does not 
extend far above the anterior articular end of the intermediary piece, the 
finger should be removed in its continuity above the disease or injury, the 
bone being severed either with a metacarpal saw or by the cutting pliers. 
An amputation in the continuity of the intermediary phalanx is preferable 
to one at the proximal intermediary articulation, as in the former case the 
insertion of the short flexor tendon is preserved, and, consequently, the power 
of flexing the stump, whereas in the latter case that power is lost, or is only 
slightly preserved through the action of one of the lumbricales muscles. 
Amputations in the contiguity of the digit are most satisfactorily executed 
by making a short dorsal flap, convex downward, and a long palmar one. 
The position of the joint may be unfailingly recognized by remembering that 
when the digit is flexed the knuckle is the upper boundary of the articulation. 
Amputation in the continuity may be performed by making either lateral 
or antero-posterior flaps. In all amputations in this part of the upper ex- 
tremity, after the dressing of the wound, the hand should be placed on a 
palmar splint. 
The knife best adapted for amputations of the phalanges is that of Pro- 
fessor Neill. It is a narrow, short-bladed, sharp-pointed bistoury, with a stout 
handle. (Fig. 1159.) 334 
AMP UTA TION. 
The difficulty usually experienced by an inexpert operator in phalangeal 
amputations done in the contiguity may be referred to the strength of the 
Fig. 1159. 
Knife for amputating the fingers. 
lateral ligaments of the joint, which, unless divided early, prevent the knife 
from entering the articulation, and to the peculiar conformation of the 
articulating extremities of the phalanges. 
A study of Fig. 1160, representing the metacarpal bone with its three 
phalanges, will greatly facilitate these amputations. 
Fig. 1160. 
The lip which projects back from the proximal end of the intermediary 
and ungual phalanges, unless the joints are flexed, will prevent the knife 
from entering the articulation ; and the fact that the condyles belonging to 
the proximal extremities of the phalanges extend beyond the centre of the 
joint shows the necessity of separating the latter by a curvilinear and not 
by a straight incision. 
Operation.-The hand being placed in the prone position, an assistant 
holds the sound fingers out of 
the way by drawing them to- 
wards the palm, while the oper- 
ator, grasping the finger to be 
removed between the thumb 
and the index finger of one 
hand, flexes the joint, while 
with the other hand an incision 
is made across the dorsal as- 
pect of the finger, from one 
side of the joint to the other, 
convex downward. The round- 
ed skin-flap being next dissected 
back, the joint is opened by 
strongly flexing the finger (Fig. 
1161) and applying the edge 
of the knife to the back of the 
articulation. The next step 
consists in dividing the lateral 
ligament with the point of the 
bistoury, first on one side and 
then on the other, after which 
the knife is passed between the articulating surfaces, and, being turned on 
its flat, is made to shave forward from the palmar surface of the finger a 
long flap, embracing all the tissues down to the bone. (Fig. 1162.) 
The digital arteries, which are necessarily divided, rarely require to be 
ligated, and the stump is closed by bringing up the long anterior flap in front 
of the phalanx and joining it to the short posterior flap by means of three 
stitches. 
Fig. 1161. 
Amputation of a finger. AMPUTATIONS IN THE UPPER EXTREMITY. 
335 
A second method of operation is to supinate the hand, and, while the fingers 
are held flexed on the palm, the blade of the bistoury is pushed across the 
front of the joint, and a long flap 
cut by carrying the knife, by a saw- 
ing motion, downward. The articu- 
lation is next opened and the bones 
separated by dividing the lateral 
ligaments on the same aspect of the 
joint, and cutting (as the knife comes 
through on the dorsal surface of the 
finger) either a straight flap or, by 
turning the edge forward, a rounded 
flap of integument. 
Amputations of the phalanges of 
the thumb are to be performed in 
the same manner as those of the 
fingers. 
Metacarpophalangeal amputations. 
-The hand having been placed in 
the prone position and the sound 
fingers drawn out of the way, the 
surgeon, grasping the injured or diseased member and placing the point of 
the bistoury directly in front of the middle of the knuckle, sinks the instru- 
ment at once to the bone, and carries an incision first directly forward for a 
short distance, and then, diverging to one side, passes through the interdigital 
cleft to the palm. 
A similar cut is made on the opposite side, the two joining on the palmar 
surface of the hand opposite the point of beginning. (Fig. 1163.) The 
incisions represent two V's, with their bases resting against each other. The 
knife is now carried upward, keeping its edge close against the proximal 
phalanx and cutting into the side of the joint, the finger at the same time 
being carried strongly to the opposite side, in order to make the ligaments 
Fig. 1162. 
Cutting anterior flap in amputation of a finger. 
Fig. 1163. 
Fig. 1165. 
Fig. 1164. 
Incision for metacarpo-phalan- 
geal amputation. 
Knife passing through 
the metacarpo-phalangeal 
joint. 
Appearance of the wound after 
amputation at the metacarpo-pha- 
langeal joint. 
tense and the articulation to gape, so that the bistoury can be carried through 
the joint (Fig. 1164), to the opposite side. Then, as the blade emerges, the 
direction of the finger must be reversed, and the operation completed by 
drawing the knife down along the opposite side of the phalanx. (Fig. 1165.) 336 
AMPUTATION. 
That the adjoining metacarpo-phalangeal articulations may come closely 
together and efface the chasm between the fingers, many advise the removal 
of the head of the exposed metacarpal bone with the cutting pliers. But as 
this enlargement atrophies in time, and as the operation exposes unnecessarily 
the cancellated structure of the bone, it is better that it should not be done. 
There is a modification of this operation,-an amputation in which the in- 
cision on the palmar aspect of the joint, instead of being prolonged into the 
palm of the hand, is carried directly across in the crease which marks the 
junction of the finger and hand. The approximation of the wound, however, 
is never so neat by this plan as by the former method of operating. 
One or two vessels usually require ligation after this amputation ; after 
which the edges of the wound should be united by two or three stitches, 
the parts covered with a piece of lint moistened with carbolated oil, and a 
still more accurate apposition 
effected by encircling the hand 
transversely with a roller band- 
age. The trifling deformity 
which follows the removal of a 
finger at this joint will bo seen 
by reference to Fig. 1166. 
Amputation of the thumb at the 
metacarpo-phalangeal articula- 
tion is executed by incisions 
similar to those made in like 
amputations of the fingers. 
Amputations of the metacarpo- 
phalangeal bones.-The removal of the whole or a part of the metacarpal 
bone, with its corresponding digit, may be required in consequence of injury, 
less frequently for disease. 
When such a procedure becomes necessary, the operation is done by a 
dorsal incision, commencing at the carpal extremity of the metacarpal bone, 
and carried forward to its phalangeal extremity or to the knuckle. Beyond 
this the direction of the knife is changed, by leaving the middle line and pass- 
ing gradually towards and through the interdigital cleft and web on one side 
into the palm, where it is to be joined to a similar cut on the opposite side, 
the two being counterparts of those made in metacarpo-phalangeal amputa- 
tions. 
The soft parts should now be dissected or crowded off from the dorsal and 
lateral surfaces of the metacarpal bone. Afterwards the ligaments uniting 
the anterior extremities of the latter with the adjoining bones are to be 
divided, when the finger, being drawn backward, will serve to raise the meta- 
carpal piece from its bed, so as to admit of its being detached from the soft 
parts connected with its anterior surface. 
The last step in the process is to effect the disjunction of the bone at its 
carpal articulation. As the deep vessels in the palm of the hand lie some 
upon and others between the metacarpal bones, great care must be taken 
to keep the edge of the knife in close contact with the bone. A probe- 
pointed bistoury constitutes the safest instrument for the deeper stages of 
the operation. 
Cases of injury will be encountered where the damage is limited to the 
anterior extremity of the metacarpal bone, or to the articulating end of the 
latter and of its corresponding phalanx, in which resection can be practiced 
and the finger preserved. 
Amputation of the thumb and metacarpal bone should be performed in such 
a manner as to preserve the entire mass of muscles forming the thenar part 
of the hand, in order that there may remain some opposing surface against 
which these fingers may act. 
If the surface of the skin is examined at the metacarpal part of the hand, 
the line of junction between the palmar and dorsal surfaces of the skin can 
Fig. 1166. 
After amputation at the middle finger. AMPUTATIONS IN THE UPPER EXTREMITY. 
337 
be clearly recognized by the contrast in the color of the two. This line, when 
the arm hangs in the natural position, is out of view or in shade, and is, on 
that account, to be selected as the line of incision, by which the resulting 
cicatrix will be concealed. 
The junction of the metacarpal bone with the trapezium is situated one 
inch in front of the styloid process of the radius, and it is at this point that 
the incision should begin, following the line already mentioned, and extending 
forward almost to the metacarpo-phalangeal joint, where it should diverge 
towards the index finger, passing through the intermediate web, and termi- 
nating on the palmar or opposite surface of the articulation. This is joined 
by a second incision, beginning at the point of divergence of the first and 
passing to the opposite side of the articulation. (Fig. 1167.) 
The muscles must now be dissected away from the bone, and the three ex- 
tensor tendons divided at the 
base of the first phalanx. The 
remaining part of the operation 
can be readily executed by using 
the thumb as a lever, dragging 
Fig. 1168. 
Fig. 1167. 
Lines of incision in removing the thumb with its 
metacarpal bone. 
Dividing deep attachments of the metacarpal bone. 
it towards the radial side of the arm or away from the index finger, dividing 
the deeper connections of the metacarpal bone backward towards the carpus, 
and finally effecting its disarticulation. (Fig. 1168.) 
If the knife has been kept close against the bone, there will be very little 
bleeding. The vessels being tied, and the sides of the wound brought together 
with three or four interrupted sutures, the remaining part of the dressing 
should be the same as in other amputations in this part of the hand. How- 
ever successful may be the cure, the loss of the thumb robs the hand of its 
beauty, force, and grace. (Fig. 1169.) 
The little finger can be removed by similar incisions made along the line of 
junction between the palmar and dorsal skin on the ulnar side of the hand, 
and by two diverging cuts, starting from the first, including the metacarpo- 
phalangeal articulation, and going in front. 
Amputation of the metacarpal bones of the four fingers.-Placing the hand in a 
state of extreme supination, enter the knife on the palmar aspect of the hand 
opposite the articulation of the metacarpal bone of the little finger with 
the unciform bone, and, pushing it across between the bones and the soft 
parts, bring its point out immediately below the thumb; carry the knife 
downward close in contact with the metacarpal bones, and cut out, form- 
ing an elliptical flap. (Fig. 1170.) Then, turning the hand in the position 
vol. ii.-22 338 
AMPUTATION. 
of pronation, make a semicircular incision across its dorsal surface, three- 
quarters of an inch below the carpo-metacarpal articulation, joining this in- 
Fig. 1169. 
Fig. 1170. 
Hand after amputation of the thumb 
and metacarpal bone. 
Amputation of the metacarpal bones 
of the four fingers. 
cision with the anterior one at both the inner and outer margins of the hand. 
It only remains now to disarticulate the different metacarpal pieces from the 
metacarpus, beginning at the index or the little finger, according as the hand 
operated on is the right or left one, and preferably from the palmar side. 
The manifold injuries to which the hand is exposed, particularly from ma- 
chinery and shot wounds, render it impossible to anticipate and describe the 
details of every amputation which may be required in individual cases. There 
are, however, certain general rules which will serve to regulate the conduct 
of the surgeon when he comes to deal with these accidents, and they may be 
formulated as follows: 
1. Perform no amputation when there is the faintest probability of saving 
the damaged part. 
2. Sacrifice no more than is absolutely necessary when an operation is un- 
avoidable. 
3. Use the skin from a finger which may be hopelessly damaged and which 
will require amputation to cover one whose skeleton and vessels remain 
sound, though its tegumentary covering may be destroyed. 
Statistics.-The mortality following amputation through the phalangeal 
and metacarpal portions of the hand is very low. In the Surgical History 
of the War there are 7902 cases of these amputations tabulated, with 223 
deaths, or, more strictly, 204 deaths, as among the fatal cases there are 19 
recorded from subsequent amputation performed higher up. 
Amputation of the Hand at the Wrist.-Surgeons are not entirely in accord 
as to the relative value of amputations through the wrist-joint and of those 
executed immediately above it. The advantages claimed for the first are the 
increased length of the level* and the preservation of the movements of 
pronation and supination. These are substantial reasons and deserve con- 
sideration. Not invariably, however, are these motions retained. The absence 
of the carpus is often, if not indeed always, followed by a degeneration of the 
inferior radio-ulnar articulation and by the production of a dense band of 
fibrous tissue, which, by anchylosis, practically destroys pronation and supi- 
nation. In a case of wrist-joint amputation which was done at Guy's Hos- 
pital by Mr. Cock, an opportunity was offered of dissecting the stump sixteen AMPUTATIONS IN THE UPPER EXTREMITY. 
339 
years after the operation. The synovial sac between the radius and ulna 
had not been opened when the amputation was performed, and yet the move- 
ments of pronation and supination were entirely lost in consequence of 
anchylosis. 
That which should determine the choice between the two operations is 
their respective mortality. We are not in possession of a sufficient number 
of wrist-joint amputations performed in civil surgery from which to deduce 
any reliable conclusions, but the annals of military surgery supply a con- 
siderable amount of data. The following results, gleaned from military 
surgery, will throw some light on the subject: 
In the Crimean War 3 successful cases of this amputation were reported. 
Chenu,* in his Report of the Campaign in the East, 1865, gives 68 cases 
of wrist-joint amputations, with 27 deaths. The same writer, in his Sta- 
tisticsf drawn from the Italian Campaign in 1869, supplies 13 cases, with 6 
deaths. 
Demmet tabulates 12 cases, with 5 deaths; Loeffler§ mentions 1 case, with 
1 death; Biefel|| reports 3 successful cases, and Ferand 1 successful case. 
Arnaud also gives 3 cures. 
Chenu analyzes 101 wrist amputations, with 69 deaths, or a death-rate of 
68.22 per cent. gives 2 cases, with one death, and MacCormac** 2 
cases, with 2 successes. 
Dr. S. W. Gross has tabulated 146 cases of amputation at the wrist-joint, 
of which number 100 recovered from the operation and 46 died,-a death-rate 
of 31.5 per cent. 
During the American civil war 68 wrist-joint amputations were reported, 
with 7 deaths,-a mortality of 10.6 per cent. Of the entire number, 55 were 
primary, with 5 deaths, or 9.2 per cent, mortality; 7 were intermediary, 
with 1 death, or 14.3 per cent, mortality; and 5 were secondary, with 3 
recoveries, 1 death, and 1 result undetermined. 
Summing up all the cases mentioned, other than those of Dr. Gross and 
Dr. Otis, we have 209, with 74 deaths,-a mortality of 35.4 per cent. This 
percentage slightly exceeds that deduced from Dr. Gross's data, and is far 
above the death-rates given by Dr. Otis. 
Operation.-The operation will be facilitated by recalling the leading 
features of the joint. The articulating surface of the radius and the trian- 
gular cartilage as it rests against the ulna is concave, the styloid processes 
of the radius and the ulna forming respectively the inner and outer bound- 
aries of the carpal arch. The three bones of the first row of the carpus, 
consisting of the scaphoid, semilunar, and cuneiform, are arranged so as to 
present a convex surface adapted to the concavity of the bones of the arm. 
(Fig. 1171.) 
In performing the operation, two semilunar flaps should be raised, one from 
the posterior and the other from the anterior aspect of the wrist and hand,- 
the latter somewhat the longer of the two. (Fig. 1172.) For this purpose 
the hand should be held in the prone position and somewhat flexed, while the 
surgeon carries an incision down to the bones and across the back of the 
wrist, from one styloid process to the other, cutting a flap convex downward 
and one inch and a half in length. This flap should now be raised and the 
posterior radio-carpal ligament incised while the hand is strongly flexed. By 
reference to Fig. 1172 it will be seen that in opening the back of the joint 
the point of the knife must be applied some distance above the plane of the 
styloid processes. If this direction be not observed, the operator will, in all 
probability, open the articulation between two rows of the carpus. 
The joint being exposed, the knife, following the arched form of the 
* Rapport, etc., pendant la Campagne d'Orient, 1865, p. 641. 
f Statistique, etc., de la Campagne d'Italie, 1869, p. 641. 
J Mil.-Chir. Studien, 1861, B. ii. S. 241. 
g General Bericht, 1867, S. 301. || Langenbeck, 1869, B. xi. S. 475. 
Chirurgie d. Schussverletzungen, 1872, S. 1842. 
Notes and Reflections of an Ambulance Surgeon, London, 1871, p. 130. 340 
AMPUTATION. 
carpus, is next applied to the lateral ligaments, the severing of which is fol- 
lowed by the separation of the articulating surfaces sufficiently to admit 
Fig. 1171. 
Fig. 1172. 
Radio-carpal articulation. 
Lines of incision in amputation at the wrist. 
of the knife being carried through the joint (Fig. 1173) and made to shave 
the anterior or palmar flap, by cutting from above downward and out- 
ward. This flap, comprising a portion of the dense 
tissue of the palm of the hand, should be longer than 
its fellow, so as to have a surface at the end of the 
stump adapted to endure pressure. 
In making this anterior flap, the surgeon should be 
careful to pass through the articulation of the pisiform 
with the cuneiform bone, including the former in the 
flap, and thereby preserving the insertion of the flexor 
carpi ulnaris muscle. The styloid processes of the radius 
and the ulna are next to be sawed off on a level with 
the cartilaginous surface of the joint, thus making the 
surface of the stump uniform. 
In cutting off the styloid process of the ulna, only the 
top should be removed. If the saw is applied too near 
the base, the triangular interarticular cartilage is liable 
to be detached and the radio-ulnar sac opened, which 
will disturb the relation of the bones. 
The radial, ulnar, and interosseous arteries, with their 
branches, being tied, the long anterior flap is brought 
up in front of the bones, and stitched, by interrupted 
sutures, to the short posterior flap. The usual dressings are then applied. 
Other modes than the one described have been employed for this amputa- 
tion, as the circular and the single anterior flap, as practiced by Guerin. 
In adapting an artificial hand to the stump after amputation at the wrist- 
joint, it is necessary to wear a sheath on the forearm and arm (Figs. 1174, 
Fig. 1173. 
Knife carried through the 
wrist-joint preparatory to 
cutting the palmar flap. 
Fig. 1174. 
Fig. 1175. 
Fig. 1176. 
Artificial arm and hand. 
Hand detached, and nipper at end of arm. 
1175, 1176), to the end of which the hand may be attached, or from which it 
may be removed at pleasure. The last figure represents a little mechanism at AMPUTATION OF THE FOREARM. 
341 
the end of the arm-piece, called 11 the nipper," which can be made to open or 
close by a motion imparted from the arm. By the aid of this ingenious ad- 
dition there are women in Philadelphia who are enabled to sustain them- 
selves by needle-work, who would otherwise be entirely dependent. This 
artificial arm is also adapted to all cases of amputation of the forearm. 
Amputation of the Forearm. 
The forearm may be amputated at any point between the wrist and the 
elbow. But when the surgeon has an election, the removal should be made 
as lowdown as possible. In planning an amputation at the carpal extremity 
of the forearm, the insertion of the supinator brevis muscle should be pre- 
served, when feasible; and in operating above the middle, the insertion of the 
pronator radii teres should not be disturbed. In the first instance the move- 
ment of supination will be retained, and in the last the function of pronation 
will remain. 
Abscess after amputation at the lower third of the forearm is more common 
than in any other portion of the member, probably in consequence of the 
numerous tendons, with their cellular investments, offering spaces for the 
retention of inflammatory products. 
At the lower third of the forearm, no method of amputation is superior to 
that by antero-posterior oval tegumentary flaps, or the modification of this 
plan with the oblique division of the muscles suggested by the author and 
illustrated on page 305, Fig. 1133. 
In performing the oval tegumentary flap amputation, the tourniquet should 
be placed over the brachial artery at the middle of the arm, so as to control 
the circulation. The forearm is then held midway between pronation and 
supination, while the operator makes two semilunar incisions, one in front 
and the other on the back of the member, extending between the radial 
and ulnar borders of the limb, and carried down to the deep fascia. These 
flaps being dissected up and reverted to an extent necessary to cover easily 
the ends of the bones, the muscles are next divided down to the bones by a 
continuous circular sweep of the knife. The interosseous structures are 
severed by pushing the catling between the radius and ulna and carrying 
it around each bone separately. The soft parts being now protected by the 
retractor, the bones are divided with the saw. 
The arteries requiring ligation are the radial, the ulnar, the interosseous, 
and, perhaps, two or three muscular branches. 
Amputation at the middle and at the upper third.-The musculo-tegumentary 
flap method is to be preferred at these localities. The proximity of the bones 
to the soft parts on the posterior aspect of the arm renders it somewhat dif- 
ficult to cut by transfixing a flap from the entire transverse extent of the 
arm, on which account the incision may be made from without inward. 
Operation.-The arm 
being held midway be- 
tween pronation and su- 
pination, a rounded or 
semilunar incision is 
made across the pos- 
terior surface of the fore- 
arm down to the bones, 
and extending from the 
ulnar to the radial bor- 
der. The flap, which 
must include the integu- 
ment and muscles, is 
next dissected up a suf- 
ficient distance and reflected. The anterior flap is now formed by pushing 
the knife across the front of the bones from the angle of the first incision 
Fig. 1177. 
Amputation at the middle of the forearm by the musculo-tegumentary flap 
method. 342 
AMPUTATION. 
on one side to that on the other (Fig. 1177), and cutting downward and out- 
ward with a sawing motion. An assistant grasping the two flaps and holding 
them back, the surgeon completes the operation by dividing the interosseous 
structures writh the catling, and sawing off the bones. 
The vessels requiring ligation are the same as in amputation at the lower 
third of the limb. 
Amputation at the upper third of the forearm is executed in the same manner 
as at the middle third. (Fig. 
1178.) 
The relation of the arteries 
and nerves to the muscles, 
and the appearance of the 
muscles as encased in their 
sheaths, can be very well 
studied in a transverse sec- 
tion of the forearm, as repre- 
sented in Fig. 1179, copied 
from the cadaver. 
The mortality following 
amputation of the forearm 
in civil hospitals is about 
13.76 per cent., while in 
American military hospitals during the late war it was almost the same,- 
13.9 per cent. 
Fig. 1178. 
Amputation at the upper third of the forearm. 
Amputation at the Elbow-Joint.-Amputation at the elbow-joint should 
always be adopted when the alternative is either to disarticulate or to cut 
off the arm above. The healing 
progresses even more rapidly 
than in operations done in the 
continuity of the arm; the 
stump presents as shapely an 
appearance as could be de- 
sired ; and there is certainly 
less constitutional perturba- 
tion than is experienced in 
amputations immediately be- 
low the joint. 
The operation is an old one, 
having been, it is believed, first 
performed by Ambrose Pare, 
in 1536, in the case of a shot 
wound in the forearm of a 
soldier at Turin, the patient 
making a good recovery. This amputation does not, however, seem to have 
attracted professional notice, as, with the exception of a single recorded case, 
nothing was heard of it until revived in Germany by Textor in 1819 and by 
Dupuytren in France in 1839, the last-named surgeon having performed the 
operation, it is alleged, with very marked success in seven or eight instances. 
The first case of this operation performed in America is attributed to an 
army surgeon, Dr. Mann,* in 1822. Dr. J. Kearney Rodgers reported a casef 
in 1828. The operation early received the sanction of Liston, who speaks 
of having done it two or three times.J With the exception of Chenu's statis- 
tics, the results of this amputation, as collected from foreign sources, have 
been very favorable, the death-rate not exceeding 14 per cent. The latter- 
named writer, however, from some inexplicable causes, in a collection of 217 
Fig. 1179. 
Section showing arteries, nerves, and muscles of the forearm: 
a, radial artery; 6, ulnar artery and nerve; c, interosseous artery; 
d, median nerve; e, interosseous nerve. 
* Medical Repository, vol. vii. 
f New York Medical and Physical Journal, vol. ii., 1828. 
j Liston's Practical Surgery, 1840, 3d edition. AMPUTATION AT THE ELBOW-JOINT. 
343 
cases of amputation at the elbow-joint, gives a mortality of over 65 per cent. 
During the War of the Rebellion 49 cases of this operation were reported, 
with 43 recoveries, 5 deaths, and 1 undetermined result. Of 4 amputations 
at the elbow-joint performed at the Pennsylvania Hospital, all recovered. 
Of 7 similar amputations at Guy's Hospital, London, 6 were cured; and of 
6 done at St. Thomas's Hospital, London, 4 recovered. In an aggregate of 
1114 amputations of all kinds performed during the last ninety-nine years in 
the Parisian hospitals, there were only 4 at the elbow, with what result is 
not stated.* 
Operation.-The most satisfactory operation, and at the same time that 
most easily executed, is one in which the stump is covered by a long anterior 
musculo-tegumentary flap, taken from the front of the arm. In doing this, 
the knife is introduced three-quarters of an inch below the internal condyle 
of the humerus, and pushed directly across the front of the arm, bringing it 
out on the opposite side the same distance below the external condyle. 
During the act of transfixing, the forearm should be supinated and flexed 
to an angle of thirty-five degrees: the object of this is to cause the anterior 
ligament of the joint to start forward, so that it shall be divided, and the 
articulation opened, as the knife crosses the front of the joint. 
The transfixion being effected, a musculo-tegumentary flap, four or five 
inches in length, must be shaved from the bones of the forearm. This should 
be completed by cutting quite abruptly out to the surface, thus forming a 
rectangular instead of a rounded termination to the flap (Fig-1180), by which 
the broad surface of the stump can be satisfactorily covered. A second in- 
cision is now made directly across the back of the joint down to the bone, 
from one side of the first wound to the other. After this the knife should 
be passed between the head of the radius and the humerus, and from thence 
Fig. 1180. 
Anterior musculo-tegumentary flap, and the anterior ligaments cut from the front of the elbow-joint, 
exposing the radius and ulna. 
across the front of the joint, between the coronoid process and the humerus; 
this movement must terminate by cutting the internal lateral ligament, when 
the articulating surfaces of the elbow will fall asunder. The operation is 
completed by sawing through the olecranon immediately above the coronoid 
process, and from before backward, thus leaving the first-named process at- 
tached to the tendon of the triceps muscle. 
The radial, ulnar, and interosseous arteries will require to be tied; after 
which the long anterior flap must be carried round the articulating end of 
the humerus, and united to the edge of the posterior flap by sutures. 
The exarticulation is sometimes effected by the circular and also by the 
lateral flap method, both of which are inferior to the one described. 
* Half-Yearly Abstract of Medical Sciences, vol. xxxvi. p. 197. 344 
AMPUTATION. 
Amputation of the Arm. 
Amputation of the arm may be performed by any of the methods -which 
have been described,-namely, by the circular or oval teguinentary flaps, by 
the Teale plan, or by musculo-tegumentary flaps. The latter is the one gen- 
erally practiced by Philadelphia surgeons. The only objection which can be 
urged against this last plan (especially wrhen applied to the lower and the 
middle third of the arm, where the biceps muscle is so movable) is the very 
unequal retraction of the integument and the muscles, the latter generally 
hanging down some distance below the former after their division. It is for 
this reason that 1 prefer the mixed method, which 1 have described on page 
305, in which antero-posterior oval skin flaps are raised, just sufficient to com- 
pensate for the difference in cutaneous and muscular retraction, and after 
dissecting up these flaps antero-posterior muscular flaps are formed, either 
by transfixion or by cutting from without inward, always terminating or 
commencing the incision, according to the course preferred, on a level with 
the base of the reflected tegumental flaps. 
Applying the tourniquet. - In applying the tourniquet in amputations 
through the lower or middle third of the arm, the instrument must be 
placed along the inner edge of the biceps or the coraco-brachialis muscle, 
the brachial artery being placed in this situation. When, however, the re- 
moval has to be undertaken high up in the upper third, the circulation will 
have to be controlled by making a few turns of a two-inch bandage through 
the axilla and over the shoulder, placing the body of the roller longitudinally 
in the axilla over the artery, against which it can be sufficiently pressed by 
the strap of the tourniquet, the base of the latter being planted upon the 
shoulder close to the neck. An assistant may also, if it be necessary, press 
the subclavian against the first rib with the handle of a door-key, as ex- 
plained under the head of hemorrhage, vol. i. page 160. The subclavian may 
also be compressed by placing a graduated compress in the hollow above 
the clavicle and forcing it upon the vessel by means of the elastic bandage 
passed across the shoulder and the opposite axilla. 
Operation.-If the ordinary plan of executing the musculo-tegumentary 
operation is adopted, the flaps (each of which ought to be from two and a half 
to three inches in length, according to the size of the arm) should be, as in 
the preceding plan, cut from the anterior and posterior aspects of the arm. 
the former, containing as it does the brachial blood-vessels, being formed last. 
Pinching up from the bone all the soft parts, consisting of the skin, fascia, 
and triceps muscle, the knife is pushed through behind the humerus from 
one side of the arm to the other, and a rounded flap is cut from above down- 
ward. The section being completed, and the divided parts held back by 
an assistant, the anterior flap is next formed by transfixing and cutting 
down-ward and forward (Fig. 1181) the soft parts in front of the humerus, 
Fig. 1181. 
Fig. 1182. 
Amputation of the arm by the musculo-tegumentary flap method. 
Appearance of the stump. 
including the integument, fascia, biceps and brachialis anticus muscles, blood- 
vessels, and nerves. The assistant retracting both flaps, the knife is car- 
ried rapidly around the bone at their base, dividing the structures which AMPUTATION OF THE ARM. 
345 
may have escaped the previous incisions. The amputation is completed by 
sawing off the humerus, leaving a deep wound. (Fig. 1182.) It 
is rarely necessary to apply a retractor in this operation. 
The arteries demanding ligation are the brachial, the anastomotic, and the 
superior and inferior profunda. 
The relation of the blood-vessels, nerves, and muscles is shown in Fig. 1183. 
After the healing is completed, a very excellent and wTell-fashioned stump 
usually remains. (Fig. 1184.) 
Fig. 1183. 
Fig. 1184. 
Relation of the anatomical components of a stump after 
amputation through the middle of the arm ; a, brachial 
artery; b, median nerve; c, superior profunda artery. 
Stump after amputation of the arm by the musculo- 
tegumentary flap method, 
In amputations of the arm, either for disease or injury, the insertion of the 
deltoid, if possible, should not be disturbed, as this muscle executes a very 
important movement,-that of elevating the arm. 
Amputation by the rectangular or Teale method may also be employed in 
the removal of the arm. 
The lines of incision for securing the long anterior flap must be made in 
such a manner that the inner one shall be sufficiently near to the margin of 
the biceps muscle not to involve the brachial artery. (Fig. 1185.) The short 
Fig. 1185. 
Lines of incision for Teale's amputation at the lower third of the humerus. 
flap is taken from the posterior aspect of the limb. After forming the flaps 
and cutting off the bone, the adjustment is made as shown in Fig. 1186. 
The mortality following amputation of the arm in civil practice is a fraction 346 
AMPUTATION. 
over 23.61 per cent. This calculation is based on an aggregate of 14,366 
cases. (See Tables of Amputations.) In military practice, the death-rate, 
Fig. 1186. 
Fig. 1187. 
Elaps adjusted in Teale's amputation of the arm. 
Artificial arm for amputation 
above the elbow-joint. 
estimated from a total of 5273 amputations performed on account of shot 
injuries, was 23.6 per cent. 
The statement that the mortality of amputations increases in a steady 
ratio as the trunk is approached, which is generally accepted as true, requires 
to be somewhat modified when applied to the removal of the upper arm, if 
Dr. Otis's figures are conclusive.* For example, it appears that in 1952 
amputations, primary, intermediary, secondary, and undesignated, done in 
the upper third of the arm, the death-rate was 18 per cent.; in the middle 
third, 1739 amputations, belonging to the same periods, gave a mortality 
slightly exceeding 16 per cent.; while in the lower third, 758 amputations 
yielded a death-rate of 26 per cent. The explanation, I think, is not to be 
found in any anatomical peculiarities of the lower third of the arm, but rather 
in the participation of its structures in the violence done to the elbow- 
joint, on account of which the amputation was rendered necessary. In civil 
practice the results will, I am confident, be found different. 
An artificial arm can be worn after amputations above the elbow-joint, and, 
though capable of being made useful in certain prehensile acts, is chiefly 
valuable for purposes of dress. (Fig. 1187.) 
The exarticulation of the arm may be effected in several ways. The most 
popular methods are those of Larrey, Dupuytren, 
Lisfranc, and Spence. 
Larrey's, or the Oval Method.-This, of the four 
named operations, is the most easily executed, and 
yields results as satisfactory as any other. 
The arm being held a short distance from the body, 
a longitudinal incision is made down to the bone; 
over the middle of the deltoid muscle, commencing 
at the acromion process and extending downward 
two inches and three-quarters. From the lower ex- 
tremity of this incision two others are prolonged,- 
the one passing in a gentle curve downward and 
backward, and the other in like manner downward 
and forward, both stopping short of the main blood- 
vessels and leaving the soft parts on the inner aspect 
of the arm undivided. (Fig. 1188.) 
These oval flaps are next dissected forward and backward until the head 
Amputation through the Shoulder-Joint. 
Fig. 1188. 
Larrey's method of amputation 
at the shoulder-joint. 
* Surgical History of the War, vol. ii. p. 805. AMPUTATION THROUGH THE SHOULDER-JOINT. 
347 
of the bone covered by its capsular ligament is seen. The surgeon now 
grasps the arm and carries it to the side of the body, while the capsule of the 
joint is freely incised in a transverse direction, exposing the head of the 
humerus. 
The next step consists in cutting the tendons of the scapular muscles, 
which are inserted in the tuberosities of the humerus. This is most effect- 
ually done by the operator grasping the arm with one hand and forcibly 
rotating the head of the humerus, first inward, so as to make tense the ten- 
dons of the supra-spinatus, infra-spinatus, and teres minor muscles, while 
with the other hand their tendons are divided by the knife. 
After the division, the arm is 
next to be rotated outward, and 
the tendon of the biceps mus- 
cle severed, and also that of 
the subscapularis from its con- 
nection with the greater tuber- 
osity of the bone. The arm is 
now to be carried backward and 
towards the side, in order to di- 
rect the head of the bone away 
from the glenoid cavity of the 
scapula when the knife is car- 
ried in between the latter and 
the neck of the humerus, pre- 
paratory to dividing the tis- 
sues on the inner surface of the 
arm. 
An assistant, leaning over the 
shoulder of the patient, now 
seizes the posterior flap between 
the thumbs and fingers of his 
two hands, following closely the 
descent of the knife, in order 
to grasp the axillary vessels as the surgeon completes his inner incision. 
(Fig. 1189.) If attention is given to these details, the time required for the 
amputation is very short. 
Should the humerus happen to be broken near 
to or at the surgical neck, the operation is rendered 
more tedious from an inability to utilize the bone as 
a lever. In such cases I have found the exarticu- 
lation expedited by seizing the upper short fragment 
with a pair of strong lion forceps, by which the piece 
can be manipulated at pleasure. 
The axillary, circumflex, and other vessels being 
tied, the flaps are to be brought together and retained 
in place by a number of interrupted sutures. The line 
of approximation will be vertical, and the stump when 
healed somewhat wedge-shaped. (Fig. 1190.) 
Dupuytren's Operation, in which two rounded flaps 
are taken from the outer and inner aspects of the 
arm, may be executed quite as rapidly as Larrey's. 
The arm being carried off at a right angle with the 
body, in order to relax the deltoid muscle, while the patient is in a semi- 
recumbent position, the surgeon pinches up the thick cushion of flesh over- 
lying the shoulder, and, introducing the point of a narrow-bladed knife two 
inches posterior to the acromion process, pushes it directly across the front 
of the joint, shaving as it advances the capsular ligament, and brings it out 
a little external to the coracoid process of the scapula. 
The transfixion being accomplished, the knife is made to follow the surface 
Fig. 1189. 
Knife dividing the tissues on the inside of the arm, and the 
thumbs in position in order to seize the axillary vessels. 
Fig. 1190. 
Appearance of the stump after 
amputation at the shoulder- 
joint. From a patient in the 
Pennsylvania Hospital. 348 
AMPUTATION. 
of the bone and to cut a rounded flap which shall terminate immediately 
above the insertion of the deltoid muscle, and which is to be turned up and 
held out of the way by an assistant. 
The surgeon next draws the arm inward and backward, making the head 
of the bone prominent, and proceeds to divide the capsular ligament. He 
afterwards severs the tendons of the biceps and scapular muscles: this will 
be facilitated by internal and external rotation of the arm, as in the Larrey 
method. 
The bone being now displaced from its socket, the knife is passed across its 
inner surface, and the internal flap formed by dividing all the structures on 
this aspect of the arm, terminating the cut in a rounded manner at the point 
where the folds of the axilla join, and controlling the axillary vessels by 
the thumbs and fingers following the descent of 
the knife, as explained in the previous operation. 
The approximation of the flaps in the Dupuytren 
operation gives a transverse cicatrix (Fig. 1191), 
instead of a vertical one, as in that of Larrey. 
Lisfranc's Operation requires for its perform- 
ance a very thorough knowledge of those move- 
ments of the scapulo-humeral articulation which 
allow of the largest space between the acromion 
and the head of the humerus. Unless these are 
distinctly understood, the knife will get locked 
and its movement will be embarrassed. The 
operation has never been popular in America. 
If the amputation is to be performed on the 
left shoulder, the knife is entered near the pos- 
terior fold of the axilla, and carried across the 
joint, between the acromion and the head of the 
humerus, emerging between the coracoid process 
and the clavicle, the arm at the same time being 
held by an assistant in the position of abduction. 
(Fig. 1192.) Pinching up the mass of the deltoid, 
the surgeon carefully conducts the knife down- 
ward over the head of the humerus, and com- 
pletes the incision by cutting a flap four and a half or five inches long. 
If this part of the operation has been executed correctly, the capsular liga- 
ment will have been opened 
and the tendon of the supra- 
scapular and the long head of 
the biceps muscle divided. 
The anterior flap being held 
out of the way by an assistant, 
the second part of the pro- 
cedure is accomplished by ad- 
ducting the arm, carrying the 
elbow in front of the chest, 
and, after passing the knife 
through the articulation, di- 
viding the tendons of the 
subscapularis, infra-spinatus, 
and teres major muscles, and 
cutting the inner flap from 
within outward. During the 
last-named movement of the 
knife, the same provision is 
made to grasp the vessels as in the other operations. 
When the operation is done on the right side, unless the operator is ambi- 
dexter, the direction of the knife in transfixion will require to be changed; 
Fig. 1191. 
stump after Dupuytren's amputation 
at the shoulder-joint. 
Fig. 1192. 
Lisfranc's method of amputating at the shoulder. AMPUTATION THROUGH THE SHOULDER-JOINT. 
349 
that is, it will have to be passed in the reverse direction from that in which 
it is used in the left. 
Spence's Operation.-Professor Spence employs a method which he regards 
as possessing advantages over all others in several particulars,-namely, in 
securing a more shapely stump, in cutting the small branches of the cir- 
cumflex artery instead of the large ones, and in the facility with which the 
disarticulation can be effected. 
In this operation the incisions are not unlike those in Larrey's, except 
that the perpendicular one is made on the inner instead of on the outer as- 
pect of the joint, and immediately external to the coracoid process, dividing 
the clavicular fibres of the deltoid and pectoralis major muscles as well as 
the humeral insertion of the latter. 
From the lower end of the perpendicular incision a second cut is carried, 
with a gradual curve, across the outer surface of the arm, dividing the fibres 
of the deltoid muscle, and terminating at the posterior border of the axilla. 
A third cut, beginning at the junction of the first and second, is next made 
across the inner side of the arm, not penetrating deeper than the superficial 
fascia, and extending through the axilla to join the second incision. (Fig. 
1193.) If the fibres of the deltoid muscle have been divided down to the 
Fig. 1193. 
Spence's plan of amputating at the shoulder-joint (Erichsen). 
bone, the anterior and outer flap containing the circumflex artery can now 
be readily raised with the aid of a finger and turned back, so as to expose 
the articulation and admit of the division of the capsular ligament, the long 
head of the biceps, and the tendons of the muscles attached to the tuberosi- 
ties of the bone: the remaining structures can then be divided on the axil- 
lary side of the arm. 
I cannot see that the advantages claimed for the operation of Professor 
Spence entitle it to any higher consideration than that attaching to the plans 
of Larrey and Dupuytren. 350 
AMPUTATION. 
The most convenient mode of retaining the dressings to a shoulder-joint 
stump is by the use of a roller applied as a spica of the shoulder. 
References are made to amputation at the shoulder-joint on account of 
gangrene by Hippocrates, Galen, and other ancient surgeons. But there is 
no evidence that the operation had been performed earlier than 1686, when 
La Roque claims to have removed the arm of a boy at the shoulder articula- 
tion in consequence of gangrene. Morand, in 1768, claimed for his father 
priority in this amputation,-a claim which is corroborated by La Faye 
in 1750. Le Dran, in his " Surgical Observations," states that his father 
successfully removed, in 1715, the arm at the shoulder-joint on account of 
disease. The first recorded instance of this operation for shot injury is one 
by Ravaton, in 1734. In this country, the earliest amputation of the kind 
was done by Dr. John Warren, in 1781, at the Military Hospital in Boston. 
Amputation at the shoulder-joint is generally a very successful opera- 
tion. After the battles of Wagram and Essling, Larrey amputated at the 
shoulder-joint 14 times, with only 2 deaths. In his final summary of opera- 
tions at this articulation, this eminent surgeon records, in a total exceeding 
100 cases, less than 9 deaths. These results are in singular contrast with 
those obtained by Guthrie and Smith. Guthrie records 38 cases of humeral 
exarticulation on account of gunshot wounds, 
embracing an equal number of primary and 
secondary operations, with 16 deaths. Dr. 
Stephen Smith's collection of shoulder-joint am- 
putations includes 71 cases, with 34 fatal ter- 
minations. 
In an aggregate of 852 cases of this ampu- 
tation (primary, intermediate, secondary, and 
undetermined) for shot injury, tabulated by 
Dr. Otis, there were 591 recoveries, 236 deaths, 
and 25 results unknown, or a mortality of 28.5 
per cent,-a fatality about the same as that 
following amputations of the arm in civil prac- 
tice. 
Notwithstanding the short stump which fol- 
lows amputation at the shoulder-joint, an arti- 
ficial member can be worn (Fig. 1194), which, for parade purposes at least, 
is fairly serviceable. 
Fig. 1194. 
Artificial limb applied after amputation 
at the shoulder-joint. 
Amputation above the Shoulder. 
Amputation of the upper extremity above the scapula may be required in 
consequence of disease or of injury, as when the arm has been torn off from 
the scapula by machinery, or has been left connected with the body only by 
a few shreds of tissue. 
When an operation of this nature becomes necessary, on account of lacer- 
ations or avulsions of the limb, it is difficult to prescribe specific rules for its 
performance. The great objects to be kept in view are to obtain a sufficient 
amount of integument to cover the wound, and to secure all vessels likely to 
bleed. 
When the arm has been torn off at the joint, the skin covering the shoulder 
is generally stripped off, or torn into narrow, ribbon-like flaps, and hence the 
necessity for occasionally dissecting out the scapula to secure a flap for the 
stump. In doing this, the knife must be kept closely applied to the bone, or 
the muscular attachments may be separated by an elevator, as in subperiosteal 
excision, with a view to avoid hemorrhage. 
During the removal, hot water may be applied to the wound to arrest 
oozing, and any vessels that are not controlled by this measure should be 
tied as the operator proceeds. 
When the amputation is a formal one, or is executed for disease, as sarcoma AMPUTATION ABOVE THE SHOULDER. 
351 
or carcinoma, the same incisions as those described (page 249) for excisions 
of the scapula, or of the clavicle and scapula, will answer the purpose. 
Results.-The history of avulsions of the upper extremity is exceedingly 
interesting, from the fact that, notwithstanding the terrible nature of the 
mutilation and the violence producing it, the patients have all recovered 
Of 14 recorded cases, in which the arm, the scapula, and, in most of the in- 
stances, a part of the clavicle have been torn off from the body, all recovered. 
Cases of Avulsion of the Arm, the Scapula, and part of the Clavicle.* 
1. Cheselden, 
1737. 
Recovered. 
8. Cooper. 
Recovered. 
2. Clouth, 
1779. 
9. King, 1845. 
3. Mussey, 
1819. 
4< 
10. Cartwright. 
C( 
4. James, 
1830. 
U 
11. Horlbeck. 1859. 
(( 
5. Scarnell, 
1832. 
a 
12. Lowe, 1866. 
a 
6. Braithwaite, 
1833. 
cc 
13. Charles, 1872. 
(C 
7. Lizars. 
CC 
14. Katholitzky, 1879. 
CC 
With the exception of one case, scarcely any blood was lost, and in most 
of the operations very little pain was experienced, which, taken in connection 
with the instantaneous nature of the occurrence, will probably explain the 
transient character of the shock and the early reaction which followed. 
Every year of hospital experience strengthens my conviction that a great 
deal more blood is lost in those accidents which demand amputation than is 
generally supposed, and that this loss constitutes the prime factor of much 
of the fatal shock which is witnessed. It would be an important step towards 
the preservation of life if it were made compulsory that the superintendents 
of all manufacturing establishments and the conductors of railroad-cars 
should be instructed in the use of the tourniquet, and that such instruments 
should be kept always on hand. 
Notwithstanding that there may be no bleeding immediately after avul- 
sion of the upper extremity, the lacerated vessels should be sought for and 
tied, for there is always danger of hemorrhage when reaction sets in. The 
patient is also exposed to the risk of secondary bleeding, after the lapse of 
seven or fourteen days, especially should sloughing occur. 
In dressing the wound at the time of the injury, any loose strips of integu- 
ment which may be present should be utilized in covering a part of the raw 
surface; provided this can be done without producing too much tension of 
the skin. 
The principal healing must be accomplished through open granulation. 
Twenty-six amputations of the arm, with a part or the whole of the 
scapula, and in some instances with a portion of the clavicle, have been re- 
ported. Of this number, 15 recovered and 11 died. 
Cases of Amputation of the Arm with the whole of the Scapula, and with or 
without a part of the Clavicle. 
No. 
Operator. 
Date. 
Disease or Injury. 
1 
Cummins. 
1808. 
Shot wound. 
Died. 
2 
Gaetani Bey. 
1830. 
Shot wound. 
Recovered. 
3 
Crosbv. 
1836. 
Osteosarcoma. 
Died 6 months after 
4 
Twitchell. 
1838. 
Malignant disease. 
operation. 
Died. 
5 
Larrey. 
1838. 
Gunshot injury. 
Recovered. 
6 
Mussey. 
1845. 
Osteoid cancer. 
Recovered. 
7 
Lewis. 
1845. 
Machinery accident. 
Died on account of other 
8 
McClellan. 
1848. 
Encephaloid growth. 
injuries. 
Died 6 months after from 
9 
Niepce. 
1860. 
Machinery accident. 
Recovered. 
return of disease. 
10 
Langenbeck. 
1862. 
Disease. 
Died 18 months after. 
11 
12 
I. C. Whishaw. 
Syme. 
1862. 
1863. 
Recovered. 
Recovered. 
® Edinburgh Medical Journal, vol. xv. Part I.; Lancet, Feb. 17, 1872. 352 
AMPUTATION. 
Cases of Amputation of the Arm (continued). 
No. 
Operator. 
Date. 
Disease or Injury. 
13 
Fergusson. 
1867. 
Tumor. 
Died. 
14 
Vincent Jackson. 
1868. 
Died. 
15 
P. H. Watson. 
1869. 
Machinery accident. 
Recovered. 
16 
K. McLeod. 
1869. 
Disease. 
Died. 
17 
Jessop. 
1874. 
Injury. 
Recovered. 
18 
Parise. 
1874. 
Cancer. 
Died from recurrence of 
19 
Parise. 
1874. 
Injury. 
Recovered. 
disease. 
20 
Parise. 
1874. 
Injury. 
Recovered. 
21 
Esmarch. 
1875. 
Recovered. 
22 
T. J. Young. 
1875. 
Railroad injury. 
Recovered. 
23 
B. B. Ross. 
1876. 
Avulsion of arm at the shoulder. 
Recovered. 
24 
Grady. 
1878. 
Disease. 
Recovered. 
25 
F. Gundrum. 
1878. 
Gunshot. 
Recovered. 
26 
Hunter. 
1879. 
Machinery accident. 
Died. 
26 
15 
11 
AMPUTATIONS IN THE LOWER EXTREMITY. 
These amputations may be divided into those of the foot, the leg, and the thigh. 
Amputations of the Foot include those of the phalanges, of the metatarsus, 
and of the tarsus. 
Phalangeal Amputations.-Except in the case of the great toe, amputations 
are rarely done in either the continuity or the contiguity of the phalanges. 
It is better, when from any cause the removal of one of the lesser toes becomes 
necessary, that the operation should be performed at the metatarso-phalangeal 
articulation, as by adopting a different course the stump would in all prob- 
ability prove an evil rather than an advantage to the foot. 
If from any circumstance an amputation is deemed desirable in the con- 
tinuity of the phalanges, it can be done in the same manner as in that of the 
fingers, viz., by a short oval flap from the dorsal surface and a long one from 
the plantar aspect of the toe. The same rule applies to amputation at the pha- 
langeal articulation of the great toe as to similar operations upon the thumb. 
Metatarso-phalangeal amputation of the toes.-The great 
size of the anterior extremity of the metatarsal bone of 
the great toe requires, in amputation at the metatarso- 
phalangeal joint, that the lateral incisions should be car- 
ried well forward, the outer one to the extreme margin 
of the interdigital web, and the inner one far enough to 
be of the same length. (Fig. 1195.) This is necessary 
to insure an abundant covering for the stump, as no 
retrenchment in the articular end of the metatarsal 
piece-as is sometimes practiced in the hand-is allow- 
able. The bone must be preserved as complete as 
possible, so as to amplify the base of support for the 
foot. 
When any one of the lesser toes is to be removed at 
the metatarso-phalangeal joint, the steps of the opera- 
tion are the same as in metacarpo-phalangeal amputa- 
tions. (Fig. 1195.) 
Amputation of all the toes is sometimes demanded on 
account of frost-bite, or from their being crushed by 
some heavy weight. 
In such a case, the extremities being held between 
the ball of the thumb and the fingers, the surgeon makes 
an incision across the phalangeal portion of the foot, 
from its outer to its inner border, and exactly on a line 
with the free edge of the interdigital webs of the toes. (See Fig. 1199.) 
Fig. 1195. 
Lines of incision for am- 
putation at the metatarso- 
phalangeal joints. AMPUTATIONS IN THE LOWER EXTREMITY. 
353 
This flap is dissected back as far as the articulations, each one of which is to be 
opened on its dorsal surface. After the entire series 
have been severed, and the toes have been well flexed, 
the knife is carried through the articulations to the 
plantai* aspect of the foot, and made to shave a flap 
from the under surface of the phalanges, as far ante- 
riorly as the web of the toes extends. 
Four or five metatarsal branches of the plantar 
arch will require ligatures, after which the two flaps 
may be brought together and stitched. The appear- 
ance of the foot after healing has been completed is 
represented in Fig. 1196. 
In cases in which the operation cannot be done in 
the contiguity of the parts, the flaps should be dis- 
sected back, and the metatarsal bones divided in their 
continuity by the cutting pliers, as it is important to 
preserve as much of the foot as possible. 
Fig. 1196. 
A stump after amputation of 
all the toes at the metatarso- 
phalangeal joints. 
Metatarsal Amputations may be limited to a single bone, or the entire row 
of the metatarsus may be removed. All amputations which are practiced on 
the foot above the metatarso-phalangeal joints are easy of execution, pro- 
vided the operator is thoroughly conversant with the topographical features 
of the foot. Without such knowledge he will be foiled at every step. 
A brief resume of the principal features of the foot will, therefore, not be 
out of place before proceeding to consider particular am- 
putations. In looking at the skeleton of the foot (Fig. 
1197), it will be seen that the three inner metatarsal bones 
posteriorly rest against and are articulated with (when 
enumerated from within outward) the internal, middle, 
and external cuneiform bones; and the two outer meta- 
tarsal pieces with the cuboid bone. 
The internal cuneiform, unlike the ■others, is placed in the 
series with its apex upward, which answers exactly to the 
instep or to the highest point on the dorsum of the foot, 
thus furnishing the key to the joint between the metatarsal 
bone of the great toe and the internal cuneiform. The 
middle cuneiform, smaller than its associates, is not placed 
on a line anteriorly with the internal and external pieces, 
but stands some distance back, forming with the other two 
a mortise, into which is fitted the second metatarsal bone, 
which, in consequence of this arrangement, is embraced by 
the internal and external cuneiforms, one on either side. 
Upon the outer border of the foot, the metatarsal bone of 
the little toe terminates in a process or tuberosity: this 
latter extends a short distance behind the surface of ar- 
ticulation with the cuboid ; and, as the prominence can 
be readily felt through the soft parts, it supplies the key to 
the tarso-metatarsal articulation on the outer side of the foot. 
The medio-tarsal articulations, or those between the as- 
tragalus and scaphoid on the inner side and the calcaneum 
and the cuboid bones on the outer side of the foot, may 
be recognized by noticing that the head of the scaphoid 
is situated one inch in front of the internal malleolus, and 
can be felt as a distinct prominence, immediately above 
which is the joint; while on the external side of the foot, 
the articulation between the os calcis and the cuboid bones 
will be seen to lie midway between the peroneal tubercle on the outer sur- 
face of the calcaneum, or the tip of the external malleolus, and the tuberosity 
of the metatarsal bone of the little toe. 
Fig. 1197. 
Bones of the foot and 
their relation to one 
another: 1, bones of the 
astragalus; 2, its head; 
3, calcaneum; 4, sca- 
phoid bone ; 5, 6, 7, in- 
ternal, middle, and ex- 
ternal cuneiform bones; 
8, cuboid bone; 9, meta- 
tarsal bones; 10, 11, 
phalanges of the great 
toe; 12,13,14, phalanges 
of the other toes. 
vol. ii.-23 354 
AMPUTATION. 
The articulation between the scaphoid and the cuneiform bones is indicated 
by the anterior surface of the tubercle of the scaphoid. By comparing the 
Fig. 1198. 
Fig. 1199. 
aa, malleoli; &&, ankle-joint, and line of incision for Syme's and Pirogoff's operations; cc, medio-tarsal joint, and 
line of incision for Chopart's amputation ; e'e', scaphoid-cuneiform joint, and line of incision for author's amputa- 
tion ; dd, tarso-metatarsal joint, and line of incision for Lisfranc's amputation; ee, metatarso-phalangeal articu- 
lation, and line of incision for amputation through these articulations. 
two figures (1198,1199) placed side by side, the articulation and the surface- 
markings indicating the joints, with the lines of incision for the different 
amputations, can be readily understood. 
As many of these amputations in the foot are done in the contiguity 
of the parts, it is necessary not only to be able to identify the individual 
articulations, but likewise to know in what manner to place the foot and 
how to use the knife in effecting their disjunction. The heel should be 
placed on the lower edge of the table, so that it may be used as a fulcrum, 
while the foot is grasped at the metatarso-phalangeal joint in one hand of 
the operator, who uses it as a lever; by this means he is enabled not only to 
make tense the ligaments of the articulations, thus favoring their division 
by the knife, but also to force asunder the joints and open the way for the 
deeper incisions. 
In severing these joints, the knife should be applied in a perpendicular 
position, and its point alone should be used, which should never be out of 
the sight of the surgeon. If more of the blade than its extremity is used, it 
is certain to become locked in the articulation. 
So important is every portion of the foot in the human economy, both for 
progression and support, that it should never be the subject of a wanton 
sacrifice of structure. Not a line more should be taken from this member 
than is absolutely necessary for the cure of the injury or disease for which 
the operation is required. I fear that the brilliant display which is connected 
with the execution of a number of these conservative operations through 
the articulations of the foot sometimes tempts the surgeon to exceed the AMPUTATIONS IN THE LOWER EXTREMITY. 
355 
limits of necessity. The laws which should govern all operative procedures 
on this part may be formulated thus: 
(1) To remove no portion, either of bone or of soft parts, unless absolutely 
required to do so by the circumstances of the case. Under this rule, indi- 
vidual bones, or even portions of such, may be extracted with success. 
(2) Even though the disease or injury may necessitate a near approach to 
a joint in the metatarsal and tarsal portions of the foot, it is better to saw 
through a bone or bones in their continuity than to enter a joint. 
(3) In constructing flaps, care should be observed to secure from the sole 
of the foot the one which is to endure pressure. 
In all these amputations through the foot, a short rounded flap is formed 
from the dorsal surface, and a long rounded one from the plantar surface. 
The hemorrhage is controlled by placing compresses over the anterior and 
posterior tibial arteries above the ankle, and over them a tourniquet. 
Several of the amputations practiced in the foot are great triumphs of 
conservative skill, and bear the names of the surgeons who have been influ- 
ential in introducing them: thus, we have the operations of Lisfranc, Hey, 
Chopart, Pirogoff, Hancock, and Syme. 
Tarso-Metatarsal Amputation (Lisfranc's).-The tourniquet being applied 
as directed, above the ankle, and the patient's heel being brought to the foot 
of the table, the surgeon grasps the foot (if the right one) in such a way that 
the thumb shall rest on the apex of the internal cuneiform bone or the summit 
of the instep, and the index finger on the tuberosity of the metatarsal bone 
of the little toe. He thus designates the two extremes of the tarso-meta- 
tarsal articulation. The position of the thumb and finger is reversed when 
operating on the left side. Between these two points a short flap is cut convex 
downward. The integument and tendons are next dissected back from the 
bones, when the knife is entered immediately behind the tuberosity of the 
metatarsal bone of the little toe, opening the joint between the first two 
bones,-the metatarsal and the cuboid bone. If the cut is made much behind 
this point, the tendon of the peroneus longus is liable to be severed. 
The point of the instrument is next applied to the ligaments uniting the 
external cuneiform and the third metatarsal bone. These being divided, the 
articulation between the middle cuneiform and the second metatarsal bone 
will have been reached, and, this being placed a 
short distance above the others, it becomes neces- 
sary to change the direction of the knife, first up- 
ward or in a longitudinal direction, second trans- 
versely, and third downward, thus following the 
boundaries of the mortise which receives the body 
of the metatarsal bone. (Fig. 1200.) It then only 
remains by a transverse cut to open the articula- 
tion between the metatarsal bone of the great toe 
and the internal cuneiform bone. In doing this 
the knife must not be allowed to pass above the 
joint, or the tendon of the tibialis anticus may be 
severed. 
While these incisions are being made, the toes 
must be forcibly depressed, so as to cause the joints 
to open (Fig. 1201), and thus enable the operator to 
complete the disarticulation by entering the point 
of the knife within the articulations and cutting 
the strong interosseous ligaments which still hold 
the bones together. 
As soon as the disjunction is accomplished, the 
long plantar flap must be formed. This is done 
by passing the knife lengthwise through the joints to the plantar surface 
of the foot, and, after turning the blade flatwise, shaving all the tissues 
Fig. 1200. 
Separating the second metatarsal 
b,'ne fr,om jt? morti8e between the 
internal and external cuneiform 
bones. 356 
AMPUTATION. 
from the bones from within outward and from above downward. (Fig. 
1201.) 
In order to ascertain the exact amount of flap necessary to cover the stump, 
it will be well, before cutting out to the surface, to remove the knife and to 
turn the detached part of the foot in front of the tarsus, for the purpose of 
measuring; and if a sufficient extent of tissue has been separated, then to 
complete the incision. (Fig. 1202.) This is the operation of Lisfranc. 
Mr. Hey, of Leeds, who first planned the tarso-metatarsal amputation, 
instead of disarticulating the second metatarsal bone from its mortise sawed 
it off on a level with the internal and external cuneiform bones. (See dotted 
line in Fig. 1198.) Numerous branches of the plantar arteries will require 
Fig. 1201. 
Fig. 1202. 
Cutting flap in a tarso-metatarsal or Lisfranc's amputation. 
Flap and front of tar- 
sal bones after a Lis- 
franc amputation. 
ligation, after which the long plantar flap is to be brought up and attached 
by interrupted sutures to the short convex dorsal flap. The stump resulting 
from this operation is represented in Fig. 1203. 
Amputation in Front of the Scaphoid Bone.- 
Cases will occur in which a Lisfranc operation, on 
account of the extent of injury, is not possible, and 
yet, if a Chopart's operation be performed, more of 
the foot will be removed than is necessary. Under 
these circumstances the articulation between the 
scaphoid and the three cuneiform bones should be 
selected for the amputation. 
Operation.-The foot being placed in the same 
position as in the tarso-metatarsal amputation, an in- 
cision, convex downward, should be made across the 
dorsum of the foot, beginning at the tuberosity of the 
scaphoid bone and terminating half an inch behind 
the tuberosity of the metatarsal bone of the little toe. 
The integument being now dissected up for a short 
distance and reflected, the point of the knife is made 
to glide round the front of the scaphoid bone and enter 
the articulation between the latter and the internal, middle, and external 
cuneiform bones; the disarticulation is favored by forcibly depressing at the 
Fig. 1203. 
Stump of the tarso-metatarsal 
amputation. AMPUTATIONS IN THE LOWER EXTREMITY. 
357 
same time the front of the foot. This accomplished, the cuboid bone is next 
sawed through with a metacarpal saw, when the knife can be passed through 
to the under surface of the foot and the plantar flap formed as in the opera- 
tion of Lisfranc. (See dotted line in Figs. 1198 and 1199.) This operation will 
give a full half-inch longer stump than that obtained by Chopart's method. 
Medio-Tarsal Amputation.-In case of injury or disease involving the foot 
to an extent incompatible with a tarso-metatarsal exarticulation, the surgeon 
may operate through the medio-tarsal joint, composed of the astragalus 
and the calcaneum above and the scaphoid and cuboid bones below. This 
operation is commonly known as Chopart's, though popularized by Syme. 
Select a point midway between the peroneal tubercle, or the external mal- 
leolus, and the tuberosity of the fifth metatarsal bone (on the outei' border 
of the foot); find the tuberosity of the scaphoid bone, a prominence about 
one inch in front of the internal malleolus (on the inner side); designate these 
two points by placing the thumb on one and the index finger on the other 
as the hand grasps the foot. A curved incision should then be made down 
to the bones between these two landmarks, with its convexity directed down- 
ward. The flap being dissected back 
a short distance, the knife is made to 
enter the joint between the head of 
the astragalus and the scaphoid, and, 
after separating these bones, is carried 
across to the outer articulation, to 
effect the disjunction between the cal- 
caneum and the cuboid. This done, a 
long plantar flap is formed by passing 
the knife through the joints (Fig. 
1204) and shaving all the soft parts 
from the bones as far forward as the 
fleshy cushion forming the ball of the 
toes. As the vertical depth of the foot 
is greatest on the inner side, the cor- 
responding portion of the plantar flap 
requires to be the longest. 
Syme preferred cutting the long 
plantar flap by transfixion before dis- 
articulating the bones,-an operation 
which is inferior to the method already 
described. 
The arteries which demand ligation are the dorsalis pedis, the internal and 
external plantar, and perhaps two or three muscular branches. 
The only error likely to be committed in the execution of Chopart's am- 
putation, and which I have seen occur, is that of getting in 
front of the scaphoid bone instead of behind it. This neec 
not happen if the surgeon will observe the articulating sur 
faces exposed. That of the astragalus is single and rounded 
while the scaphoid anteriorly presents three distinct artic 
ulating facets for the three cuneiform bones. 
The stump resulting from a Chopart's amputation is 
represented in Fig. 1205. 
An objection of some force is urged against Chopart's 
operation, in that the anterior tendinous attachments being 
necessarily cut away, the gastrocnemius and soleus mus- 
cles tend to draw the heel upward, in consequence of which 
the cicatrix becomes exposed to pressure in walking, and 
hence is liable to undergo ulceration. This, however, is not 
an insuperable evil. The division of the tendo Achillis and 
the subsequent flexion of the stump until the gap is filled up will correct 
Fig. 1204. 
Forming the flaps in Chopart's amputation. 
Fig. 1205. 
Stump after the medio- 
tarsal amputation. 358 
AMPUTATION. 
the vicious position. The necessity for tenotomy after this amputation may 
be obviated by maintaining the leg in a flexed position, so as to relax the 
muscles of the calf, until the stump has healed. The same end may be 
attained by moulding to the back of the leg and the heel a neatly-fitting felt 
splint. 
Subastragaloid Amputation.-This operation, first performed by M. De 
Lignerolles, and afterwards by Textor, according to Velpeau, consists in 
removing all the bones of the foot except the astragalus. Mr. Hancock, 
in 1864, introduced a modification of the operation, which possesses certain 
advantages over the original, inasmuch as the posterior part of the calcaneum 
is left, and is applied against the under surface of the astragalus, from which 
a thin slice of bone has been sawed. This amputation must necessarily be 
followed by less shortening of the limb, and by a more effective power over 
the ankle-joint. It may become necessary in certain diseased conditions of 
the tarsal bones. 
It is performed in the following manner. An incision is commenced below 
the external malleolus, cutting down upon the bone, and carried forward 
along the outer border of the foot to a point a little in advance of the tuber- 
osity of the metatarsal bone of the little toe. A second incision is made 
along the inner border of the foot, beginning below the internal malleolus, and 
ending at the base of the metatarsal bone of the great toe. A third cut is made, 
curved with its convex face downward, across the sole of the foot, uniting 
the anterior extremities of the two longitudinal cuts. The plantar flap is 
now dissected back as far as the tuberosities of the calcaneum, keeping close 
to the bones. A fourth incision is next made across the dorsum of the 
foot, immediately behind the head of the astragalus. A saw is now to be 
applied to the under surface of the calcaneum, in front of the tuberosities, 
and the bone cut from below upward and backward. This effected, the 
astragalo-scaphoid joint is laid open, and the knife carried in between the 
astragalus and the calcaneum, dividing the interosseous ligaments, separating 
the anterior portion of the os calcis from the astragalus, and detaching the 
front of the foot from its posterior connections. 
It now only remains to saw off the head of the astragalus, to secure the 
plantar arteries, and to bring together the flaps with sutures, when the 
operation is completed. The difference between the subastragaloid opera- 
tion and the modification of Hancock consists chiefly in the removal, in the 
former method, of the entire os calcis. 
This amputation has rarely been performed. 
Amputation at the Ankle-Joint.-Originally this amputation was performed 
by taking flaps from the sides, from the entire circumference of the foot, and 
occasionally a single one from its dorsum. The skin from these regions 
being entirely unsuited to endure pressure, the operation passed into disuse, 
until revived in 1843 by Syme and by Roux, the former demonstrating the 
possibility of employing the hard tissue of the sole of the foot for a flap, and 
the latter accomplishing a similar object by using an extensive covering of 
integument taken from the inner and lateral portions of the foot. 
Syme's Amputation is executed as follows. The foot being placed at a 
right angle to the leg, an incision down to the bone is carried in a forward 
direction across the sole of the foot from the anterior border of the top of one 
malleolus to that of the other. A second cut is carried across the front of 
the ankle on a curved line with its convexity directed forward, and joining 
the extremities of the first incision at an angle of forty-five degrees. The 
dense tissue of the heel covering the calcaneum is now to be carefully dissected 
off from the bone, the thumb being interposed between the soft parts and the 
knife, while the latter is kept closely applied to the irregularities of the 
osseous surface, that the flap may not be button-holed. (Fig. 1206.) While it 
is important that the integrity of the fleshy cushion shall be preserved, so as AMPUTATIONS IN THE LOWER EXTREMITY. 
359 
to avoid sloughing, it is possible that an error may be committed by going 
to the other extreme and raising with the flap portions of the periosteum 
from the calcaneum, in which nodules of bone 
may subsequently appear and keep up a trouble- 
some irritation. Roux witnessed two instances of 
this kind, which would militate against the method 
of Macleod and Bell, who propose in this amputa- 
tion to preserve all the periosteum of the calca- 
neum. 
As soon as the plantar surface of the os calcis has 
been cleared, the joint must be opened in front by 
cutting through the anterior tibio-tarsal ligament. 
Afterwards, the lateral ligaments are to be severed 
with the point of the knife, passed between the 
astragalus and the malleoli. In dividing the innei* 
ligament, the operator should be careful not to 
injure the posterior tibial vessel, which lies im- 
mediately behind the internal malleolus. It is 
always wise to avoid inflicting unnecessary dam- 
age on this blood-vessel, as an accident of this 
kind might seriously compromise the vitality of 
the flap. Mr. Erichsen and Mr. Lister allege that 
the integrity of the posterior tibial is not material 
to the life of the heel-flap. A careful dissection, 
however, of a well-injected foot will show that 
branches from the external plantar artery are 
largely distributed to the tissues of the heel,-a 
fact which has received particular notice from 
Dr. Wyeth, of New York. The interosseous artery 
frequently terminates in the same part of the foot. 
Sometimes a considerable branch is supplied to it 
from the posterior tibial immediately above its division into plantar vessels. 
It is in view of this arterial distribution that I prefer to carry the incision 
across the plantar surface of the foot from the anterior border of the tip 
of one malleolus to that of the other, as the parts will be divided in front 
of the nutrient vessels. (See Fig. 1209.) 
The last step in the operation consists in detaching the tendo Achillis from 
the calcaneum, clearing away the soft parts from the malleoli, and sawing 
off the latter, including a slice of the cartilage covering the tarsal end of the 
tibia. The heel-tissue, being brought forward over the end of the bone, is 
now attached to the anterior flap. 
The success of this operation depends in no small measure 
on the accuracy with which the posterior flap is made to 
rest against the end of the tibia and the fibula. Its cup- 
shaped form results from the shape of the os calcis, from 
which it is dissected; and, if cut too large and not suffi- 
ciently flattened out by pressure when applied to the bones 
of the leg, it is liable to form a sac or pouch for the collection 
of purulent formations. When such accumulations occur, 
an aperture may be made through the flap and a small 
drainage-tube introduced. 
The stump after a Syme amputation (Fig. 1207) is well 
adapted for support, and the shortening of the limb rarely 
exceeds one and three-quarter inches. 
Sedillot, Mackenzie, and Pirogoff have each made a modi- 
fication of this operation,-the two former by taking the 
principal flap from the inner and plantar surface of the foot 
and the ankle; and in cases where the soft parts on the outer side of the 
foot have been destroyed, their operations will prove quite satisfactory. 
Fig. 1206. 
Dissecting out the os calcis in a Syme 
amputation. 
Fig. 1207. 
Stump after Syme's 
amputation. 360 
AMPUTATION. 
In a total of 266 cases of Syme's amputation, which includes 219 analyzed 
by Hancock and 47 reported during the American civil war, only 26 proved 
fatal. Of the operations recorded by Hancock, 187 were done for disease, 
with 11 deaths,-a mortality of 5.9 per cent.; and 32 for accident, with 6 
deaths,-a mortality of 19 per cent. 
Pirogoff's Amputation. - Pirogoff, of St. Petersburg, in 1852, modified 
Syme's operation by utilizing the posterior portion of the calcaneum and 
applying it to the under surface of the tibia and fibula. By this plan a more 
solid base of support is obtained, as well as less shortening of the limb. 
The operation is executed in the following manner. An incision is made 
across the front of the ankle, extending from the anterior border of the tip 
of one malleolus to that of the other, slightly convex forward, and about 
three-quarters of an inch in front of and below the ankle-joint. A second 
incision is carried across the sole of the foot and down to the bone, uniting 
the extremities of the for- 
mer. The plantar flap is now 
dissected up from the bone 
for a short distance, not ex- 
ceeding three-eighths of an 
inch; after which the an- 
terior or dorsal flap is to be 
raised, exposing the front of 
the joint and the malleoli. 
The articulation is next to 
be opened by cutting the an- 
terior and lateral ligaments, 
when the astragalus can be 
carried forward from between 
the malleoli by depressing 
the foot. A narrow-bladed 
or a butcher's saw is now 
applied to the calcaneum im- 
mediately behind the pos- 
terior lip of the astragalus, 
and the bone sawed obliquely through in a direction downward and forward. 
(Fig. 1208.) The operation is completed by dissecting the soft parts back 
from the malleoli and saw- 
ing them off with the carti- 
laginous incrustation on the 
articular surface of the tibia, 
as in Syme's operation. 
The relation of the incision 
through the soft parts to the 
bones, and the direction in 
which the os calcis and the 
bones of the leg are sawed, 
are represented in Fig. 1209. 
In the adjustment of the 
parts, the denuded surface of 
the os calcis is brought up 
and applied against that of 
the tibia. If the section of 
the calcaneum has been suffi- 
ciently oblique, the bony sur- 
faces will come neatly to- 
gether without causing any unusual tension of the tendo Achillis; but if not, 
it is necessary either to remove another slice from the bones of the leg, or 
to divide the tendon subcutaneously. I prefer the latter procedure. 
Fig. 1208. 
Sawing the os calcis through in Pirogoff's amputation. 
Fig. 1209. 
Lines of incision, and the direction in which the calcaneuni and 
the bones of the leg are sawed. Relation of the branches of the ex- 
ternal plantar artery to the heel: a, line of section of os calcis; &, 
lines for dividing the soft parts; c, line for sawing the tibia and 
fibula; d, arterial distribution. AMPUTATIONS IN THE LOWER EXTREMITY. 
361 
Several years ago, in performing this operation, instead of sawing off the 
malleoli and the articular surface of the tibia, I allowed them to remain, and 
placed the calcaneum in the mortise between the two: the union was com- 
plete, and was followed by a remarkably useful stump. In other instances I 
have done this, and with satisfactory results. (Fig. 1210.) 
It is not always, however, that such a disposition of the remains of the os 
calcis is possible. There is a remarkable absence of anatomical uniformity 
in the size of the os calcis as compared with the 
intermalleolai' space. Frequently the former is 
too wide to enter the latter. When this is not 
the case, the above plan should be adopted in 
preference to the original one, as the calcaneum 
is less liable to be displaced. The union of the 
bones will be somewhat hastened by paring away 
the incrusting cartilage from the inner surfaces of 
the malleoli and from the articular face of the 
tibia. 
Pirogoff's operation is usually very successful, 
both as regards the subsequent usefulness of 
the limb and small risk to life. Of 147 cases 
of this amputation collected by Hancock, Gross, 
and Pasquier, only 14 proved fatal (a death-rate 
of 9.52); 101 were known to have recovered 
with excellent limbs, and 5 required subsequent 
amputation of the leg. 
The modifications of the Pirogoff operation 
which have been proposed at different times pos- 
sess no merits over the plan already described. 
Sedillot advised that the tibia and fibula should 
be divided upward and backward. Pasquier di- 
rects that both the bones of the leg and the eal- 
caneum be sawed horizontally. Pirrie, in cutting 
the os calcis, sawed from below upward ; the same surgeon cut off the lower 
extremities of the tibia and fibula, antecedent to disarticulation. Bontecou, 
in forming the plantar flap, cut from within outward. The appearance of 
the stump after Pirogoff's amputation is shown in Fig. 1211. 
In summing up the relative merits of the different opera- 
tions practiced on the foot, it may be said that their value 
diminishes in proportion to the amount of bone removed, 
though the least favorable of them all is superior to an am- 
putation above the ankle. A proper estimate of their im- 
portance will also depend, in some measure, on the nature of 
the cause for which the operation is done. 
It is thought by some that in cases of disease these ampu- 
tations are scarcely admissible, as structural changes of the 
tarsal bones are more likely to be general than local, and that 
it is consequently better to amputate above the ankle. This 
opinion is not in accordance with my experience. The bones 
in front of the medio-tarsal articulation may be the subjects 
of caries without necessarily implicating the other pieces of 
the tarsus, and may be removed, leaving the latter to form a 
permanently useful.stump. 
The metatarso-phalangeal amputation detracts very little from the useful- 
ness of the foot. That of Lisfranc or Hey, though diminishing the base of 
support, is followed by no very serious physical disability. The objection to 
Chopart's operation-that of the elevation of the heel by the shortening of 
the muscles of the calf of the leg-is easily removed, as has been shown, by a 
subcutaneous division of the tendo Achillis. Pirogoff's amputation is open 
to the same objection as that urged against Chopart's, namely, the elevation 
Fig. 1210. 
Calcaneum placed between the mal- 
leoli and solidly united to the bones. 
(Taken from a specimen in the author's 
collection, affording an excellent illus- 
tration of the result of such an opera- 
tion.) 
Fig- 1211- 
stump after Piro- 
goff's amputation. 362 
AMPUTATION. 
of the heel; but this difficulty is obviated by keeping the leg well flexed until 
union between the osseous surfaces has taken place. 
The stump resulting from the operation of Syme, although free from the 
tendency to displacement and better adapted (in consequence of the absence 
of the projection of the heel) to receive an artificial limb, requires a longer 
period than a Pirogoff before it will endure the superincumbent weight of 
the body. 
Amputation of the Leg. 
Amputations through the different parts of the lower extremity are per- 
formed by tegumentary and by musculo-tegumentary flaps, both symmetrical 
and asymmetrical. Lines indicating the gen- 
eral plan of these amputations are shown in Fig. 
1212. 
When it becomes necessary to sacrifice the 
foot, and the surgeon may elect any point of the 
lower part of the leg for an amputation, it is 
desirable that the operation be done about three 
inches above the ankle; and this for three rea- 
sons, namely, safety to life, the mechanical ad- 
vantages of a long lever, and its aptitude for 
receiving an artificial limb. The method best 
suited for amputation at the lower third of the 
leg is that by anterior and posterior oval or by 
lateral tegumentary flaps and a circular division 
of the muscles. 
Operation.-The surgeon, standing on the 
outside of the extremity (if it be the right leg), 
makes an oval incision, convex downward, across 
the anterior part of the limb, commencing at 
the inner angle of the tibia, half an inch below 
the point where it is contemplated to saw 
off the bone, and terminating at an opposite 
point on the outer border of the fibula. This 
incision should include a flap at least two and a 
half inches in length, and should be carried 
down to the deep fascia. The flap being dis- 
Fig. 1212. 
Fig.1213. 
Lines of incision in the different ampu- 
tations of the leg and thigh. 
Amputation at the lower third of the leg by the antero-pos- 
terior oval tegumentary flap method. 
sected from the subjacent parts and reflected, a similar flap of equal extent 
is to be formed on the posterior part of the leg, and turned back. Both 
flaps are next to be loosened up for half an inch at the angles formed by the 
junction of the two incisions. The integument being now retracted, the 
muscles are to be divided at the base of the flaps by circular sweeps of the 
knife; after which the interosseous structures are to be severed, by pushing 
the catling between the bones and carrying it repeatedly around each 
until all the adhering tissues are divided. The bones are then to be sawed 
off on a level with the division of the muscles. (Fig. 1213.) The vessels 
requiring ligation are the anterior and posterior tibials, the peroneal, and 
two or three small muscular arteries. AMPUTATION OF THE LEG. 
363 
The rectangular or Teale operation is sometimes performed in this part 
of the leg, but it has no advantages over the oval flap method. The long 
Fig. 1214. 
Lines of incision in Teale's amputation at the lower third of the leg. 
flap is taken from the anterior portion of the limb, and the short one from 
Fig. 1215. 
Flaps adjusted. 
the posterior, which will include the posterior tibial artery. (Figs. 1214, 
1215.) 
Amputation at the Upper Third.-The removal of the leg at its upper or 
middle third is most satisfactorily accomplished by forming a short convex 
flap of integument from its anterior surface, and a long musculo-tegumentary 
flap from its posterior aspect. 
Operation.-Assuming the operation to be done on the right side, com- 
mencing at the inner angle of the tibia, the knife is carried first downward, 
then across the limb, and finally upward, to a point on the outer side of the 
fibula, opposite the point of beginning, cutting a semilunar tegumentary 
flap two and a half inches in length. The latter, being raised from its 
deep attachments and reflected, is held out of the way by the surgeon's 
fingers, while the knife is made to transfix the limb at the angle of the first 
wound, taking care to pass behind and not between the bones. A long flap 364 
AMPUTATION. 
is then cut from the entire width of the calf of the leg, three, four, or 
more inches in length, according to the size of the limb. (Fig. 1216.) The 
Fig. 1216. 
Section of the leg at its upper third. 
operation is concluded by retracting the flaps, dividing the interosseous 
structures with the catling, intro- 
ducing a retractor, and sawing off the 
bones on a level with the retracted 
parts: the fibula must be severed be- 
fore the tibia or at the same moment 
with it. 
The anterior and posterior tibial, 
with the peroneal and interosseous ar- 
teries, and some branches of the sural 
vessels, will demand ligation. 
The relative position of the compo- 
nents of the leg as they appear after a 
circular section at the upper third is 
shown in Fig. 1217. Before closing the 
wound it will be proper to round the 
front of the tibia, by sawing away an 
oblique slice from its spine for the pro- 
tection of the anterior flap. 
The hemorrhage having been ar- 
rested and the nerves retrenched, the 
posterior flap is brought forward and 
stitched to the anterior one, which is brought down likq a hood over the 
bones. 
The after-treatment of this amputation demands more than usual attention. 
The posterior flap must be well supported, so that there may be no drag upon 
the anterior flap over the tibia, which might seriously jeopardize its vitality 
and cause ulceration. To prevent this, some surgeons diminish the W'eight 
of the posterior flap by slicing a portion of its thickness. A cushion of oakum 
(placed between the calf of the leg and the pillow on which it rests) will 
furnish the necessary support. 
When the amputation is done high up, there is always a strong disposition 
in the leg to become unduly flexed, through the contraction of the ham- 
string muscles. This must be counteracted by keeping the limb on its pos- 
terior surface, and, if this is not sufficient, by adjusting a posterior splint to 
the same aspect of the leg and thigh. It is rarely necessary to resort to 
tenotomy in order to correct the vicious position and prevent rigidity of 
the knee-joint. A stump resulting from the above amputation is very well 
represented in Fig. 1218. 
Fig. 1217. 
The bones, muscles, and principal arteries of the 
leg at the upper third as seen after a circular ampu- 
tation : a, anterior tibial artery; b, posterior tibial 
artery; c, peroneal artery. AMPUTATION OF THE LEG. 
365 
No removal of the leg should be performed above the tubercle of the tibia. 
The division of the tendo patelhe destroying all power to extend the stump, 
and the close proximity of the joint exposing the articulation to inflamma- 
Fig. 1220. 
Fig. 1218. 
Fig. 1219. 
[Stump after amputation of the upper 
third of the leg. 
tion, together with the large expo- 
sure of the cancellated tissue of 
the tibia furnishing a convenient 
avenue for the introduction into 
the system of the poisonous prod- 
ucts of decomposition, are cogent 
reasons for condemning such an 
amputation. 
The artificial limb worn after 
amputation of the leg may be either that generally known as the "peg leg" 
(Fig. 1219), or the more elegant mechanism of Mr. Kolbe (Fig. 1220). 
Mortality.-Amputation of the leg, when performed fbr disease, may be 
considered a very successful operation, the mortality depending on the part 
of the limb removed, and steadily increasing as the knee is approached; it is 
also influenced by the age of the patient, being less in children than in adults. 
The average death-rate is about 25 per cent. 
Amputations of the leg performed on account of injury yield a higher 
mortality. Bryant estimates it as high as 60 per cent. Malgaigne states 
that in the Parisian hospitals it was 63.3 per cent. American hospitals cer- 
tainly furnish no such death-rate as this, the mortality being, according to 
the tables on mortality after amputations, etc., 31.50 per cent. 
Peg leg. 
Artificial leg. 
Amputation at the Knee-Joint. 
Amputation at the knee-joint involves less shock to the general system 
than the removal of the limb at the upper third of the leg, and, in my own 
experience, is followed by as quick a union. It is always to be preferred, 
when the condition of the articulation will permit, to any amputation through 
the condyles of the femur. 
The earliest notice of this amputation is that by Fabricius Ilildanus, in 
1581, who was the first to amputate at this joint. For one hundred and 
eighty-three years following, no attention appears to have been given to 
the operation, until it was revived in 1764 by Hoin, receiving then also the 
commendation of Petit and Brasdor. Notwithstanding the support accorded 
it by these distinguished surgeons, there appears to have lingered a strong 
professional prejudice against the operation, as it was still doomed to over 
half a century of forgetfulness until revived and made popular by Velpeau 
in 1830. In 1824, Dr. Nathan Smith amputated at the knee-joint, and his 
operation was the first of the kind done in America. Indeed, the subject 
has received more attention in this country than abroad, and has been more 
popular as an amputation in the United States than with our transatlantic 
brethren. 
Operation.-Amputation at the knee-joint may be executed in four differ- 366 
AMPUTATION. 
ent ways: first, by the oval method, or that of Baudens, which consists of 
a long anterior and short posterior flap; second, by a long anterior flap; third, 
by triple flaps, known as the plan of the elder Professor Pancoast; and, fourth, 
by lateral flaps. 
The antero-posterior flap, or oval method, is the one which I generally 
employ, as, in my judgment, possessing advantages over other operations. 
The limb being extended and brought over the end of the table, an incision 
(if the left leg be the subject of amputation), commencing near the posterior 
border of the internal condyle and a little below the level of its tuberosity, 
is made directly down the inner side of the leg, to a point two or three 
finger-breadths below the level of the tuberosity of the tibia; it is then 
carried across the front of the leg in a slightly curved line to the opposite 
side, and from thence upward to a point on the external condyle of the 
femur answering to that on the internal condyle where the knife was first 
applied. The integument is rapidly dissected up as high as the tubercle of 
the tibia, when an assistant flexes the leg, thereby making tense the tendo 
patellae, which is next to be divided, and after it likewise the capsular liga- 
ment, thus exposing the cavity of the articulation. 
The surgeon now turns back the anterior flap containing the patella 
(Fig. 1221), and, leaving the liga- 
mentum mucosum undisturbed, di- 
vides the lateral and crucial ligaments. 
In cutting the crucial ligament, care 
should be exercised not to wound the 
popliteal vessels with the point of the 
knife. 
The disarticulation being accom- 
plished and the leg well flexed, the 
knife is passed through the joint, and 
made to cut a musculo-tegumentary 
flap, three inches in length, from the 
posterior aspect of the limb. The 
semilunar cartilages should next be 
removed from their ligamentous con- 
nections with the tibia. 
The object in directing that the 
extremities of the anterior incision 
should not extend higher than the 
tuberosities of the femur is to avoid severing those bands of fascial and 
fibrous tissue which serve to connect the involucrum of the joint, and with 
it the quadriceps muscle, to these portions of the bone. When this direction 
is disregarded and the incision is carried higher, the powerful muscles of 
the thigh, realizing no check, are liable to retract and strip the condyles of 
the femur. It is to resist this same tendency that it has been advised not 
to cut the ligamentum mucosum, which extends between the intercondyloid 
notch and the anterior flap. The necessity for beginning and terminating 
the anterior cut far back is that its extremities may conduce to an easy 
drainage. 
Another question of some importance is, what disposition to make of the 
patella. Should it be dissected out from its bed in the anterior flap, as some 
advocate, or should it be allowed to remain ? The excision of the bone 
renders the vitality of the flap precarious. My own practice has been always 
to allow it to remain; and I have never discovered any evil resulting from so 
doing. Its tendency to be drawn up on the anterior face of the thigh has 
been urged as an objection to its presence. But this is easily obviated by 
following the directions already given in reference to not carrying the in- 
cision for the anterior flap too high on the sides of the condyles. Neither 
is there any valid reason for removing the articular cartilage, when it is 
sound, from the condyles of the femur, as some have advised. It should not 
Fig. 1221. 
Anterior flap raised, containing the patella, and the 
knife passed through the joint preparatory to cutting 
posterior flap. AMPUTATION OF THE LEG. 
367 
be disturbed. The idea that its disintegration retards the process of healing 
is not sustained by experience. Nor is it desirable to remove a thin slice 
from the under surface of the patella, as is occasionally done. If, however, 
the section is made from the surface of the condyles, the patella should be 
similarly treated, and the two surfaces applied against each other, in order 
that union may be effected. 
In ligating the popliteal vessels, the vein and artery, which normally are 
very closely united by connective tissue, must be separated, and not tied 
together, as otherwise, during the subsequent ulceration of the thread, the 
cavities of the two might communicate and give rise to an arterio-venous 
aneurism. The vein will often demand a ligature. I have tied it in several 
instances without causing any trouble. 
In addition to the popliteal artery, four or five smaller branches, as the 
articulars and the surals, may require to be secured. 
In adjusting the wound, the long anterior flap is carried, as a hood, over 
the condyles of the femur, and is stitched to the short posterior flap. The 
dressing being now applied to the stump, the thigh should be somewhat 
elevated, and a roller bandage carried up the limb to the groin,' so as to 
resist the retraction of the muscles. 
The long anterior flap.-In adopting this method, the anterior flap is cut in 
the same manner as in the previous operation, differing only in its length; 
it should extend nearly four inches below the tubercle of the tibia. Tbe 
tissues on the back of the knee are divided directly across, joining the ex- 
tremities of the anterior incision. (See Fig. 1224.) After the disarticulation 
the anterior flap is folded round tbe condyles of the femur and united by 
sutures to the edge of the posterior wound. 
Triple flaps.-This plan is original with Professor Pancoast: the operation 
is performed by making a short oval flap anteriorly (the patella being in- 
cluded) and two latero-posterior flaps, which join in the middle of the popliteal 
region. 
Lateral flap method.-This is the operation of Professor S. Smith, of New 
York. The flaps are tegumental, and are made by two incisions, which, be- 
ginning one inch below the tubercle of the tibia, diverge over the sides of 
the leg and join each other posterior to the articulation. The patella is also 
retailed in this operation. 
The stump which results from a successful amputation at the knee-joint 
has an excellent form, is well adapted to receive an artificial limb, and admits 
of being advanced by the quadriceps muscle, as in the ordinary movements 
of walking. 
Results.-Dr. Markoe, of New York, in a collection of 46 cases drawn 
from the practice of American and European surgeons, found the mortality 
to be 37 per cent.,* while Dr. John H. Brinton, of Philadelphia, in an aggre- 
gate of 164 casessfauthis amputation, ascertained the death-rate to be in 
chronic disease 22.58 per cent., for injury 40.62 per cent., and for both to- 
gether 32.31 per cent., Ill of the patients dying and 53 Mr. 
Lane analyzed 60 cases, with 21 deaths,-a mortality of 35 per cent. As far 
as published, the records of the Surgeon-General's Office furnish 211 cases, 
with 106 deaths, or a mortality of 50.2 per cent. If with these data wTe 
compare the results of amputation of the thigh done for shot injury during 
the late American war, it will be seen that in the latter the mortality is about 
19 per cent, greater than in the former,-namely, in 1597 cases of thigh am- 
putation there were 1029 deaths, or a mortality of 64 per cent. When am- 
putations of the leg and of the knee are contrasted, we find the fatality of 
the two to be about the same,-namely, from 32 to 33 per cent. 
* New York Journal of Medicine, 1856. 
f American Journal of the Medical Sciences, April, 1868. 368 
AMPUTATION. 
Amputation at the Thigh. 
Amputations may be made in any part of the thigh. They may be arranged 
in three groups,-namely, amputations in the lower extremity, in the shaft, and 
at the upper extremity of the bone. 
Those at the lower end of the femur may be termed condyloid and supra- 
condyloid amputations. 
Condyloid Amputations.-Circumstances may occur to necessitate ampu- 
tation and the articular end of the femur may be found to be in a diseased 
condition. In such an event the leg may be removed by forming two oval flaps, 
one from the front and the other and 
shorter from the back of the knee, 
the first extending from the most 
prominent part of one condyle to 
the corresponding point on the 
other side, and crossing the leg 
two inches below the tubercle of 
the tibia. (Fig. 1222.) The integu- 
ment is to be dissected up from 
over the patella, and the latter bone 
is to be separated from its muscular connections above and turned down. 
The articulation being now opened and its ligaments divided, the posterior 
flap may be cut in two ways,-either by raising a semilunar flap, consisting 
of integument, and making a transverse cut through the muscles and tendons 
on the back of the condyles of the femur, or by carrying the knife through 
the articulation, as in an ordinary knee-joint amputation, and shaving a mus- 
culo-tegumentary flap from the posterior aspect of the limb. Whichever 
plan is adopted, after its execution the condyles of the femur are to be 
sawed off1 on a level with their cartilaginous incrustation; and, after securing 
the vessels, the flaps are to be brought together and united by sutures, the 
line of approximation being near the posterior aspect of the stump. 
Long Posterior Flap.-Another form of condyloid amputation is that in 
which a short and slightly oval flap is first cut from the front of the knee, and 
a long musculo-tegumentary one from the calf of the leg. 
The knife is drawn across the knee at the upper margin of the patella 
and from one condyle to the other, cutting through the integument, fat, 
fascia, and quadriceps extensor muscle, and opening the joint, after which 
follows the division of the lateral and crucial ligaments, when the knife 
is carried through the articulation and a long and broad flap cut from the 
calf of the leg. The articular surfaces of the condyles are next sawed off; 
and, after securing the vessels, the posterior flap is brought up in front of the 
bone and stitched to the short flap on the anterior face of the thigh. This 
operation supplies a very excellent stump, and one well adapted to tolerate 
pressure. 
Carden's Amputation.-This amputation, which was introduced in 1846, 
consists in cutting a rounded tegumental flap from the front of the knee, suf- 
ficiently long to cover the end of the stump, and 
which requires that the incision shall extend 
below the tubercle of the tibia. The integument 
being dissected up from the patella and the knee 
flexed, the remaining soft parts are divided by a 
circular sweep of the knife down to the bone, and 
then retracted, after which the femur is sawed 
off at the base of the condyles. 
In dressing the wound, the anterior flap is 
turned beneath and attached by sutures to the 
edge of the posterior wound. (Fig. 1223). 
The advantages of the condyloid method over an operation performed in 
Fig. 1222. 
Lines of incision in a condyloid amputation. 
Fig. 1223. 
Carden's amputation.-From Bryant. AMPUTATION OF THE LEG. 
369 
the shaft of the femur are very apparent. The medullary canal is not opened, 
a greater length of leverage is preserved to the limb, the danger to life is 
lessened by increasing the distance from the trunk, fewer vessels are divided, 
and, of course, less blood is lost, in addition to which the integument forming 
the end of the stump is well suited to endure pressure. The operation has 
proved eminently successful in Mr. Carden's hands, that surgeon having 
reported 30 amputations with only 5 deaths. 
Gritti's Operation.-The operation to which this name is applied is no 
novelty in Philadelphia, having been done many years ago by Dr. George 
Fox at the Pennsylvania Hospital, and more recently, 
in the same institution, by Dr. Hunt. By this method 
an anterior tegumental flap is formed from the front 
of the knee, by carrying an incision from two inches 
above one condyle of the femur to a similar point on 
the other side, and crossing the leg immediately below 
the tubercle of the tibia. The integument is raised, 
the tendo patellae divided, and the flap turned back, 
containing the patella, from the under surface of which 
a thin slice is sawed off. A short tegumental flap, 
slightly convex downward, is now dissected up from 
the back of the knee, the synovial membrane is di- 
vided in front of the joint, and the femur sawed off 
above its articular surface. (Fig. 1224.) The opera- 
tion is completed by dividing the remaining soft parts 
from without inward, when, after tying the vessels, 
the long anterior flap, containing the patella, is brought 
down and the freshened surface of the latter applied 
to that of the condyles, somewhat as the os calcis is 
made to rest against the lower end of the bones of the 
leg in Pirogoff's amputation. 
Fig. 1224. 
aa. Lines of incision in form- 
ing long anterior and short 
posterior flaps in knee-joint 
amputations; b b b, incision in 
supra-condyloid amputation of 
the thigh by the Gritti plan. 
Section of the patella and 
femur in Gritti's condyloid 
amputation indicated by the 
dotted lines. 
Supra-Condyloid Amputation. - This operation is 
known as that of Stokes, of Dublin, and differs from 
Gritti's only in sawing off the femur sufficiently near 
to the base of the condyles not to expose the medul- 
lary canal, and bringing in contact the cancellated tissue of the lattei* bone 
and the patella. 
Amputation in the Shaft of the Femur.-The thigh may be removed at any 
point between its articulating extremities, but it is of vital importance that 
not one inch more than is absolutely necessary be cut away, for the fatality 
of these operations rapidly increases as we ascend the limb. 
The methods of thigh amputation which are employed by surgeons are, 
that of the musculo-tegumentary flaps, double, single, and lateral, the method 
of semilunar tegumentary flaps, and the Teale or rectangular method. 
The musculo-tegumentary flaps possess, in my judgment, advantages over 
all others, and should be cut from the anterior and posterior aspects of the 
limb. As the skin retracts very much more than the muscles, I always em- 
ploy a modification of the musculo-tegumentary plan, which I have explained 
under the head of preliminary or general remarks on amputations. 
It is done as follows. Two semilunar flaps are raised to the extent of one 
inch and a half from the anterior and posterior aspects of the limb. These 
being reverted and held out of the way by the fingers of an assistant, the 
muscular and other components of the limb are divided, by pushing the 
knife through at the angles formed by the junction of the first incisions, and 
by cutting out to the surface of the limb at the line where the tegumentary 
flaps are reflected. In forming the muscular flaps, the anterior one should 
be cut first when operating below the middle of the thigh, as it does not 
contain the femoral blood-vessels. But, when operating above the middle, 
vol. ii.-24 370 
AMPUTATION. 
the posterior flap should have precedence, as the vessels are situated an- 
teriorly. 
The flaps being turned back and retracted by an assistant, the amputating 
knife is swept around the femur on a level with the reverted tissues, in order 
to clear the bone, at which point the saw is applied and the limb severed. 
The vessels requiring ligation at the 
lower half of the thigh are the femoral, 
the anastomotic, and four or five muscular 
branches from the deep femoral. The 
relations of the muscles, blood-vessels, and 
Fig. 1225. 
Fig. 1226. 
Relation of the components of the stump after 
a transverse section of the thigh: a, femoral ar- 
tery ; b, femoral vein; c, muscular or perforating 
arteries. 
Anterior flap in thigh amputation divided by transfixion and 
reverted. 
nerves are exhibited in Fig. 1225, taken from a transverse section of the 
thigh. 
The musculo-tegumentary flap operation, as ordinarily performed, is more 
simple, but less satisfactory when the parts are being adjusted. 
The operator, when ampu- 
tating below the middle of the 
thigh, pinches up between the 
thumb and fingers all the soft 
parts in front of the femur, 
transfixes the mass as near to 
the bone as possible, and cuts 
obliquely downward and for- 
ward a flap one-third longer 
than half the diameter of the 
limb. This flap being reflected, 
a similar one (Fig. 1226) is now 
cut from the posterior part of 
the thigh, by passing the knife 
through at the angles of the 
first wound, between the mus- 
cles and the bone, and cutting 
downward and backward. (Fig. 
1227.) The posterior flap is 
sometimes formed by trans- 
fixion and cutting from within 
outward, and the anterior one by cutting in the opposite direction, or from 
without inward. 
Vermale's amputation of the thigh by lateral musculo-tegumentary flaps, 
though favorable to drainage by the vertical disposition of the wounds, 
is objectionable on the ground that, from the weight of the soft parts, 
the end of the bone is liable to become exposed at the upper angle of the 
wound. 
The rectangular or Teale method has only a limited application in this part 
Fig. 1227. 
Amputation of the thigh,-anterior and posterior flaps re- 
tracted preliminary to sawing off the bone. AMPUTATION OF THE LEG. 
371 
of the limb, as in a majority of cases demanding amputation of the thigh it 
is attended with too great a sacrifice of the member. 
Amputation in the Trochanteric Part of the Femur.-Amputation even 
through the trochanters is preferable to disarticulation at the hip-joint. It 
may be required on account of severe injuries involving the upper half of 
the thigh, or for morbid growths, such as enchondroma. The method of 
removing the thigh in this situation does not differ from that employed 
lower down. And even if, after proceeding to the amputation, the disease 
or injury requires the disarticulation of the limb, the latter operation is in 
no way interfered with. 
Artificial Limb.-The artificial limb which is ordinarily employed after 
thigh amputation does not materially differ from that used for the leg. 
(Figs. 1228 and 1229.) 
Results.-The mortality attending amputation of the thigh is very con- 
siderable; but it is influenced 
much by the circumstances 
demanding the operation, by 
the place of removal, by the 
age of the patient, by the 
period at which the operation is 
done, and even by the hospital 
in which the case is treated. 
Shot wounds. - When per- 
formed on account of shot 
wounds, the fatality, always 
very heavy, varies greatly. 
Among the French troops, 
both in the Crimea and in 
Italy, the mortality of thigh 
amputations was 90 per cent. 
During the late American 
war, so far as ascertained, it 
was 64 per cent. Taking to- 
gether the results of English, 
French, and American opera- 
tions, it is about 77 per cent. 
Dr. S. W. Gross, in a very 
elaborate paper* on the sub- 
ject of thigh amputations for 
shot wounds, has formulated 4123 cases, 977 of which recovered and 3146 
died,-a death-rate of 76.30 per cent. The same writer has classified 729 
amputations of the thigh in a manner to exhibit the mortality as determined 
by the particular part of the limb removed: thus, of 236 amputations per- 
formed in the lower third of the thigh, 130 died,-a death-rate of 55.08 per 
cent.; of 268 in the middle third, 175 died,-a mortality of 65.26 per cent.; 
and of 225 in the upper third, 177 died, or 78.66 per cent. 
Primary amputations, whether performed in military or in civil life, are 
about 25 per cent, more fatal than secondary amputations. In civil hospitals 
the average mortality of thigh amputations is about 52.33 per cent. 
A much more favorable result is obtained wThen the thigh is amputated for 
chronic disease. In a collection of 348 cases made by Bryant, 81 died,-a 
mortality of 23.27 per cent. 
The influence of age on the mortality is very marked. Selecting as an 
illustration amputation done for chronic disease of the hip- and knee-joint, 
it will be found that under the age of twenty years the mortality is about 
2 deaths in 23 cases of amputation, while over that age it is about 33 per 
cent. 
Fig. 1228. 
Fig. 1229. 
Artificial limb for the thigh, with an exposure of its internal 
mechanism. 
* American Journal of the Medical Sciences, October, 1867. 372 
AMPUTA TION. 
Amputation at the Hip-Joint. 
Perhaps no operation in surgery more strikingly exhibits the amazing 
power of enduring mutilation possessed by the human body, or better illus- 
trates the boldness of surgery, than an amputation at the hip-joint. Under 
the most favorable circumstances the danger to life is so great that only 
when no alternative remains should the operation be undertaken. 
Among the causes which may render it necessary to amputate at the hip- 
joint are shot fractures and other injuries involving the articulation and 
accompanied with extreme laceration of the soft parts immediately around; 
lesion of the femoral artery at the groin ; osteomyelitis; and morbid growths 
at the upper part of the thigh. 
The mortality following these amputations arises from hemorrhage, pri- 
mary and secondary; from exhaustion, either from shock or prolonged 
suppuration; and from the complication of surgical fever. With proper pre- 
cautions there need be very little loss of blood at the time of the amputation, 
though no amount of forethought can effectually guard against secondary 
hemorrhage. In this way I lost a patient fourteen days after the removal 
of the limb at the hip. 
Amputation at the coxo-femoral articulation may be performed in several 
ways. Among these may be named that by circular and oval tegumentary 
flaps, and that by antero-posterior or by lateral musculo-tegumentary flaps. 
The methods which admit of 
the most rapid execution, and 
which are attended with the 
least possible loss of blood, are 
those by the oval tegumentary 
and the antero-posterior mus- 
culo-tegumentary flaps. 
Whatever plan is selected, one 
of the first considerations is to 
prevent the effusion of blood. 
With this object in view, the 
Esmarch elastic bandage should 
be applied to the limb from the 
toes upward, sufficiently high 
not to interfere with the con- 
struction of the flaps. In this 
way the blood can be forced out 
of the vessels of the extremity 
into the body. As soon as the 
elastic cord is placed around the 
limb, at the point where the bandage ceases, the latter can be removed. 
This done, the abdominal tourniquet of Dupuytren, as modified by Professor 
Pancoast (Fig. 1230), should be placed around the body, and the pad screwed 
down upon the aorta until all pulsation in the femoral arteries is found to 
have ceased. 
In the application of this instrument the following directions will be found 
of value. The patient should be turned upon his right side, in order that the 
intestines may be rolled over in that direction and so escape the pressure of 
the instrument, which otherwise might seriously injure their walls, and also 
that as little of the contents of the abdomen as possible shall intervene 
between the aorta and the abdominal parietes. That the pressure may be 
concentrated on the vessel, a roller bandage should be previously fastened 
to the pad of the instrument. The pad, in order to act with accuracy, must 
be placed over the abdominal walls immediately to the left of the umbilicus. 
Another method of preventing hemorrhage during this amputation is by 
" Davy's lever," an instrument which is designed to compress the aorta 
Fig. 1230. 
Abdominal tourniquet. AMPUTATION OF THE LEG. 
373 
through the rectum. In a case operated on by W. M. Armstrong at the 
Greenwich Hospital School, this device was adopted with entire success. 
Operation by Oval or Oval Tegumentary Flap.-This method, though 
less rapidly executed than the musculo-tegumentary plan, possesses certain 
advantages which, in my judgment, entitle it to precedence over all others. 
It can be done with a very small loss of blood, and in its performance we get 
rid of the mass of muscular tissue which enters into the musculo-tegumentary 
flaps, and which, during the suppurating period, retains in its crevices a large 
amount of pus, which, undergoing decomposition, exposes the patient to the 
risk of blood-poisoning. 
In executing the operation, the patient, after being etherized, and after the 
limb is emptied of its blood and the tourniquet applied, is brought down 
with the hips projecting over the lower end of the table. An assistant now 
takes hold of and supports the limb, while the surgeon makes a semilunar 
incision in front of the limb, with its convexity downward, and commencing 
midway between the anterior superior spinous process of the ilium and the 
trochanter major on the outside, descending the thigh in a longitudinal direc- 
tion for five inches, then passing across the front of the limb in an oval course, 
adding thereby an inch to length of the flap, and, last, ascending the 
inner border of the thigh, and terminating one inch below the ramus of the 
pubis. The integument is now rapidly dissected up from the deep fascia, and 
intrusted to the fingers of an assistant. 
The next step is to isolate the femoral vessels above the origin of the pro- 
funda, and to apply, separately, to the artery and the vein a strong ligature. 
By displacing the pectineus muscle the obturator artery can be readily found 
and ligated below the obturator membrane. 
The limb being now raised, the surgeon proceeds to cut a semilunar tegu- 
mentary flap from the back of the thigh, one inch shorter than the anterior. 
With an amputating knife the muscles are then severed circularly in front of 
the joint, when the assistant having charge of the limb carries it in a back- 
ward direction, thus causing the head of the femur to press against the front 
of the capsular ligament, and giving the surgeon an opportunity to divide 
the latter, and, after it, the teres ligament. This done, the bone imme- 
diately starts from its socket, when, the limb being rotated inward, the 
operator is enabled to carry the knife through the joint and behind the great 
trochanter, completing the operation by cutting through the muscle on the 
posterior aspect of the joint. 
The moment the limb is severed from the body, one or two soft napkins 
should be thrust against the surface of the wound, particularly its posterior 
part, so as to prevent bleeding, and should only be removed by installments, 
as the vessels are exposed and tied. 
After the arteries have been secured, a drainage-tube should be inserted and 
the flaps stitched together, when the line of approximation will be found 
sufficiently dependent to drain off all accumulations from the wound. 
The dressings applied to the stump to absorb the discharges can be conve- 
niently retained in place by a spica roller. 
This operation, though apparently somewhat tedious, may, by a dexterous 
operator, be completed in forty seconds. 
Musculo-Cutaneous Flap Method.-The preliminary arrangements being 
made as in the operation just described, embracing the position of the patient 
and the application of the abdominal tourniquet, an assistant, grasping the 
limb, flexes the thigh somew'hat on the pelvis, so that the capsule of the joint 
may be relaxed and made prominent. The surgeon, using a narrow-bladed 
knife, twelve or thirteen inches long, enters its point half-way between the 
trochanter major and the anterior superior spinous process of the ilium, and, 
pushing it across the front of the joint, shaving the capsule of the latter as 
it advances, brings it out on the inner side of the limb at the junction of the 
thigh with the scrotum, the latter being held out of the way. With a rapid 
sawing motion a broad flap six inches long, consisting of muscle and integu- 374 
AMPUTATION. 
ment, is cut downward and outward. Before the knife is turned towards the 
surface in forming the flap, the latter is grasped between the thumbs and fin- 
gers of an assistant, who stands between the operator and the side of the 
patient, and who both compresses the vessels and retracts the divided mass. 
The assistant who holds the limb now quickly carries it backward, when, 
the capsule being incised, the head of the bone leaves the acetabulum. The 
round ligament is next severed, the limb rotated inward, and the knife passed 
through the joint to the pos- 
terior aspect of the limb, from 
which a musculo-cutaneous flap 
five inches long is now cut. 
(Fig. 1231.) 
History. - Morand appears 
to have been the first surgeon 
who first seriously contemplated 
this formidable amputation, and 
doubtless it was the influence of 
his opinions which inspired the 
two essays presented in 1739 to 
tlie Royal Academy of Surgery 
in Paris by Volner and Puthod, 
both of whom had been pupils 
of Morand. It was not, how- 
ever, until 1760 that this opera- 
tion received the approbation of 
the learned men composing the 
Academy of Surgery, and that 
chiefly through a communica- 
tion to this body by Barbet, who not only defended the operation, but 
specified the cases which seemed to demand its performance. Numerous 
other similar papers followed that of Barbet. 
The first operation of the kind on the living subject is attributed to 
La Croix, of Orleans, in 1748. This, however, cannot be strictly regarded 
as an amputation in any sense, as the limb of the patient (a boy fourteen 
years old) had undergone an almost entire spontaneous separation, con- 
sequent on the sloughing of ergotism, leaving the ligamentum teres and the 
sciatic nerve to be severed. The lad died fourteen days after the operation. 
The first successful case of this amputation was done nearly about the same 
time in France and in England,-in the former by M. Perrault, of Saint-Maur, 
in 1773, on account of gangrene following an injury, and in the latter, it is 
believed, by Mr. Thompson, of the London Hospital. Whether the case 
credited to the last-named surgeon be authenticated or not, there remains no 
doubt that, in 1774, Mr. Kerr, of Northampton, performed an amputation 
at the hip-joint for hip-disease in a little girl, who died from phthisis pul- 
monalis eighteen days after the operation. Little more was heard of this 
amputation until about 1794, when Blandin recorded three cases in which he 
removed the limb at the hip-joint for shot injuries, two of whom recovered, 
and the third survived the amputation two months. These cases were fol- 
lowed by one of Perret, another French military surgeon, one in 1796, by 
Mulder, and by three cases of Larrcy, two of which were done during the 
campaign in Egypt, and the third while on the Rhine with the French army. 
In December, 1812, the first successful case of this operation by an English 
surgeon was performed by Mr. Brownrigg, on a soldier who had suffered a 
severe shot fracture in the upper part of the femur while in Spain. 
In America, Dr. Brashier, of Kentucky, in 1806, performed the first suc- 
cessful operation of this kind, and another was done with a like favorable 
result by Dr. Mott. In Philadelphia, amputation at the hip-joint has been 
performed by Dr. Duffy, Professor Gross, the two Pancoasts, Hewson, Packard, 
Ashhurst, Forbes, Hunter, Morton, and myself. 
Fig. 1231. 
Hip-joint amputation. AMPUTATION OF THE LEG. 
375 
Results.-The statistics of hip-joint amputation embrace at present a large 
number of cases, amounting to more than 500. In 122 amputations, 111 of 
which have been taken from Circulars No. 7 and No. 2 issued from the Sur- 
geon-General's Office, and 11 from othei* sources, 38 recovered and 84 died,- 
a mortality of 69 per cent. In 175 amputations for shot wounds, the death- 
rate amounted to 90 per cent. 
The fatality of primary amputations at the hip-joint is one-third greater 
than that following secondary operations. There is also a great difference 
in the death-rate according as the amputation is performed for disease or for 
injury. In 45 cases of the former 21 died, while in 43 of the latter 36 proved 
fatal. 
Re-amputation at the hip-joint yields quite a favorable result, 5 out of 8 
cases recovering,-a death-rate of 37 per cent. CHAPTER XVIII. 
SHOCK-TRAUMATIC FEVER. 
Shock is a term used to express the collective phenomena which follow the 
infliction of some violence to the body through the nervous system. It may 
be defined to be a partial suspension of the functions of organic and animal 
life. 
Symptoms.-In light cases of shock there may be experienced only a slight 
pallidity of the surface, accompanied by a sense of muscular weakness, a little 
nausea, and a few drops of perspiration standing on the brow or the face. 
In more severe or typical cases, the first effect is seen in a depressed state of 
the heart. The pulse is feeble, thready, slow, becoming, after a time, more 
frequent, and occasionally irregular. The countenance is pale; the face 
shrunken ; the alee of the nose dilated ; the eye dull and without lustre, the 
lids half closed; the skin shrunken, cold, and clammy, or wet with perspira- 
tion ; the breathing quiet, scarcely perceptible, and now and then interrupted 
by sighs. There is great muscular prostration, the patient lying supinely 
in one position, generally on the back. There may be also paralysis of the 
sphincters of the bladder and rectum. Sometimes there is mental stupor or 
bewilderment, though often the mind is perfectly clear and rational. The 
special senses participate in the general disturbance. The vision and the 
hearing are less acute than naturally, and the same is true of olfaction, gus- 
tation, and general sensibility. In addition to the above symptoms, there 
are others less commonly noticed, as tremor, muscular twitchings, intolerance 
of light, vertigo, and vomiting. 
The temperature in shock is ordinarily very little below the normal degree. 
In slight cases the symptoms of shock may pass over in a few minutes; 
but in those of greater severity they may continue fbr hours, and even for 
one or two days. In some instances there exists an exciting struggle between 
reaction and depression ; the system makes a gallant attempt to recover from 
the influence of the violence; the symptoms in some measure abate, but the 
recuperative effort is not sustained, the tide of battle turns, and the forces of 
the enemy again become dominant. And so the conflict is waged, now the 
one and then the other yielding 
or advancing, until the struggle 
closes either by recovery or by 
fatal collapse. 
A number of sphygmographic 
tracings, taken at my request, 
at the Pennsylvania Hospital, 
by Dr. Mcllvaine, in cases of 
shock, exhibit in a very marked 
degree the loss of arterial ten- 
sion indicative of great cardiac 
feebleness. Fig. 1232 is a pulse- 
tracing taken from a patient 
who, in consequence of being run over by a heavy truck, had his thigh and 
pelvis fractured, and who died on the evening of the fourth day succeeding 
the accident. The pulse would frequently change in a period of fifteen 
minutes from seventy-five to one hundred and twenty beats. The tempera- 
ture at no time exceeded 99°, and just before death it fell to 9fi°. 
Fig. 1232. 
Pulse-tracing in a case of shock. 
376 SHOCK. 
377 
When reaction takes place, it is announced by a gradual amelioration of 
the symptoms. The power of the heart begins to increase, and, as a conse- 
sequence, the strength, fullness, and regularity of the pulse. The blood comes 
out of its lurking-places in the deep organs of the body, and finds its way to 
the surface in more generous streams ; the color begins to return to the face 
and the lips; the warmth of the trunk, and still later that of the extremities, 
is felt again; the clammy moisture bedewing the surface dries away; the 
respiration becomes fuller and freer, and the operations of the mind resume 
their orderly action. As in concussion of the brain, one of the earliest signs 
of reaction after shock may be the occurrence of vomiting. 
When, on the other hand, a fatal termination is to follow, death may be 
sudden, produced by heart-spasm, the ventricles forcibly contracting and then 
ceasing to beat. Generally, however, the fatal approach is more gradual. 
The innervation of the heart becomes more and more imperfect, and, conse- 
quently, its power is lessened, so that the pulse is at the 
wrist. The temperature continues to fall; the power of utterance or motion 
is entirely lost; and the patient sinks into a state of unconsciousness ending 
in death. 
Traumatic delirium.-Reaction from shock may occur in another manner. 
After one or several attempts on the part of the system to recover from the 
depression, reaction is finally established; but, as in the swing of the pendu- 
lum, the opposite extreme is reached. The skin becomes dry and hot, the 
pulse is full and throbbing, but soft and compressible, the face is flushed, the 
conjunctiva is injected, the respiration is short, hurried, and broken by feeble 
sighs, the tongue dry and tremulous, the thirst urgent, and, in addition, there 
are continued nausea and vomiting. The stupor and apathy of shock are 
exchanged for restlessness, jactitation, and subsultus of the tendons. The 
sleep is fitful, broken, and uneasy. The orderly operations of the mind are 
disturbed,-a result sometimes expressed in a quiet delirium or incoherent 
muttering, at other times in great irritability or in singular caprice, and often 
in maniacal raving. 
The excitation of the nerves and of the circulatory system may gradually 
subside and recovery follow. Should, however, the disease tend to a fatal 
issue, the former symptoms are followed by extreme exhaustion; a cold, 
clammy sweat breaks out, the pallor returns to the face and lips, the counte- 
nance assumes a careworn, haggard expression, the eyelids are nearly closed, 
the pulse becomes feeble, rapid, and tremulous, and the scene is closed by 
convulsions ending in profound coma and death. 
In such a picture there may be an illustration of that wonderful provision 
which resides in the organization to meet extraordinary emergencies, and 
which, though conservative, is nevertheless often destructive. The heart, 
deprived of the nerve-power necessaiy to fulfill its task of supplying suffi- 
cient blood to the organs and tissues of the body, attempts to supplement the 
deficiency by increasing the number of its beats. This increase of function 
with a lessened source of power must necessarily be followed by exhaustion 
and the reappearance of symptoms of prostration, the danger of the patient 
being greatly enhanced. 
The above symptoms answer to that condition which Mr. Travers* has 
described as sometimes following shock, and which he designated " prostra- 
tion with excitement," in which the energies of the system are diminished by 
excessive reaction. 
Nervous delirium.-In some instances, during the reaction from shock a 
group of symptoms develops resembling those which belong to delirium 
tremens, sometimes called nervous traumatic delirium. When occurring in 
a person of intemperate habits, it may be considered as an attack of mania 
a potu. The dominant features of this state are a feeble, rapid pulse, a 
moist skin, a heavily-loaded tongue, which is very tremulous when protruded 
from the mouth, and either a blustering or a muttering delirium, in which the 
* Travers on Constitutional Irritation, p. 475. 378 
SHOCK. 
mind is annoyed with some single hallucination, but which can be dissipated 
for a time when the patient's attention is drawn to some other subject. In 
persons whose health has been damaged by intemperance and other forms of 
debauchery such a condition forebodes great danger. It is usually ushered 
in by insomnia and restlessness. 
The reaction which follows shock, especially in females, may take a hys- 
terical turn, the patient screaming, crying, singing, or laughing, according to 
the mental mood. 
Secondary shock.-A patient may rally from the effects of an operation, and, 
after a few hours, may relapse into a state of alarming exhaustion. The 
symptoms attending this condition are a lowering of temperature, a feeble 
pulse, a pinched expression with pallor of the face, occasional vomiting, an 
unusually rapid respiration, and often a state of mental indifference. The 
whole group of symptoms indicate an insufficiency of heart-power. The 
motor resources of the cardiac ganglia appeal* to have been expended in 
establishing reaction after the operation, and, consequently, are unable to 
supply the necessary power to continue or to sustain the heart's action. A 
frequent cause of death, as a result of the feeble circulation, is the formation 
of a heart-clot, which, by preventing the contraction of that organ, finally 
arrests its action altogether. This coagulum may also disintegrate into frag- 
ments, or emboli, as they are termed, which, borne away upon the blood- 
stream, become impacted in the small pulmonary and cerebral arteries, 
forming serious obstructions to the circulation in these vessels. 
This secondary shock is not uncommon after prolonged surgical operations 
and after severe railroad and other injuries in which there has been extensive 
contusion or laceration accompanied with considerable loss of blood. 
Causes.-The causes of shock are psychical and physical, external and 
internal. They may act singly or conjointly. 
Psychical.-The influence of the mind over the organic functions of the 
body is very remarkable. The action of the heart is increased by the emo- 
tion of joy, diminished by grief or despair. A strong mental impression 
sometimes disturbs the function of the liver and induces an attack of jaundice. 
The stomach may become deranged, the secretion of the kidneys suspended 
or increased, and the milk of the nursing mother rendered entirely unfit fbr 
use, from emotional causes. Numerous instances of sudden death have fol- 
lowed the announcement of both joyful and depressing news. Nothing more 
fully exemplifies the intimate interdependence of mind and body than the 
rapidity with which a patient sinks who has been the subject of a mortal 
injury, but who, ignorant of its true nature, has been buoyed up by hope until 
the conscientious physician, constrained by a sense of duty, informs the suf- 
ferer of the near approach of death. Criminals, whose eyes have been ban- 
daged, and who have been informed that they were to be bled to death, are 
said to have died under the impression that the operation was being per- 
formed, although not a drop of blood was lost. A slight scratch made over 
a vein, and a little stream of water falling audibly into a basin, were suf- 
ficient to counterfeit the opening of a vessel and the flow of blood. 
Physical.-Among the physical causes of shock may be enumerated, as 
most prominent, falls, blows, injuries of the head, of the spine, and of large 
joints, railroad and machinery accidents, gunshot wounds, burns, and scalds. 
Doubtless, in most instances of violence both the mind and the body are 
concerned in producing the symptoms of shock. The fright incident to the 
injury, the horror of impending destruction, must, independent of the physi- 
cal harm or lesion, constitute a powerful source of depression. This, perhaps, 
is most noticeable in railroad collisions, in which many persons, though at 
first unconscious of having sustained any bodily damage, fall into a condition 
of fatal collapse after the period of excitement has passed over. 
There are also internal causes which are as potential in causing shock as 
any external traumatic violence, such as the passage of a biliary or renal 
calculus, the perforation of the stomach or intestine by cancerous ulceration SHOCK. 
379 
or from the effects of enteric fever, a developing peritonitis, the serous dis- 
charges of cholera, and a strangulated bowel. Severe pain may also bring 
on a fatal collapse. 
Intensity of Shock.-The severity of shock depends on a variety of con- 
ditions. 
(1) Constitutional peculiarities, mental and physical.-A timid or cowardly 
person, exposed to some sudden accident, will, even though the bodily injury 
may be slight, suffer a more serious prostration than one who is fearless and 
indifferent to danger. 
Travers relates the case of a colored man received into the London Hos- 
pital suffering from a moderate-sized aneurism of the femoral artery. When 
the patient was introduced into the amphitheatre for the operation, he ap- 
peared agitated, and fainted ; and before the ligation was completed he was 
dead.* The same writer adduces the case of a man who, being seized with a 
strangulated hernia, expired from fright before the preliminary measures 
necessary for the operation were completed. The autopsy showed that there 
was nothing in the condition of the bowel to explain the death. 
Again, there are persons who are in no way deficient in boldness and courage, 
who, upon sustaining a trivial injury, are seized with tremblings, faintings, 
stupor, and frightful exhaustion. Sir Astley Cooper mentions the instance 
of a strong, vigorous man who had been suffering for some days with an 
abscess of the finger, caused by a splinter of wood. An incision was made 
to give vent to the matter, when the patient raised himself from the bed in 
a convulsive manner and immediately expired. Such results can only be 
explained on the theory of some individual peculiarity or idiosyncrasy of 
organization. 
In contrast with the above is another class, of a cold, phlegmatic tempera- 
ment, hard-grained persons with iron nerves and coarse muscles, defiant of 
pain, who endure all forms of mutilation with apparently little sensibility 
or depression. 
(2) The diffused nature of the injury has also much to do with the produc- 
tion of shock. A scald or a burn becomes serious, both as regards shock 
and prospective inflammation, more by the extent of surface involved, how- 
ever superficial the lesion may be, than by its depth when the damage is more 
limited. 
A leg or an arm may be hopelessly mangled or crushed, and yet, if the 
effects of the violence are confined to the injured part, there will probably 
be but a slight or temporary depression of the general vitality, unless the 
constitutional factor of a peculiarly sensitive organization comes in to in- 
tensify traumatic effects. On the other hand, if the body has been included 
in the injury, as often happens in railroad and machinery accidents, the shock 
will be prominently marked. 
Many cases of instantaneous death are the result of diffused or general 
concussion of the body. 
(3) The organ or region of the body implicated.-A severe contusion of the 
testicle, or a rupture of an intestine, is attended with much greater prostration 
than a wound of the brain. A blow delivered upon the abdomen produces 
a much more depressing effect on the nerve-centres than a similar violence 
inflicted on the chest; and a fall upon the head will be followed by a more 
pronounced shock than that which succeeds to a crushed upper or lower ex- 
tremity. The same is true of the extirpation of tumors situated in the deep 
regions of the neck, as compared with the removal of similar growths of 
much greater bulk in less vital regions of the body. The avulsion of a toe- 
nail causes a greater shock than the removal of the mammary gland. The 
crush of a joint, like that of the knee, is productive of a greater shock to the 
system than a similar injury of the thigh,-a fact probably explained by the 
complex nature of an articulation. 
* Travers on Constitutional Irritation, p. 23. 380 
SHOCK. 
(4) Kind of injury.-All wounds or injuries are not alike productive of 
shock. Incised wounds, if the hemorrhage is promptly arrested, occasion 
less constitutional depression than lacerated wounds. A missile may carry 
away a portion of the skull and its contents, and yet cause less shock than 
a force which fails to fracture any part of the cranium. 
(5) Loss of blood.-If, in addition to the injury, there follow an excessive 
loss of blood, the symptoms of shock are intensified by the dangerous com- 
plication of syncope, which stands in relation to the vascular system very 
much as shock does to the nervous system. It is owing to this loss of blood 
that so many persons who are brought into our hospitals with crushed limbs 
never rally from the injury. 
(6) Age, and habits.-The extremely aged and the very young possess little 
power to resist the depressing influences of external injury; and those who 
by a life of vicious excesses of any kind have enfeebled the body arc alike 
vulnerable. 
Nature of Shock.-How the violence or the emotion acts upon those central 
ganglionic masses of neurine whose office it is to sustain and regulate the 
functional operations of organs, is a question which physiology has not an- 
swered. Considered from a clinical stand-point, it is evident, first, that the 
determining cause of shock must reach that portion of the nervous system 
through either the spinal, the cerebral, or the cerebro-spinal nerves, from 
which the heart and the lungs receive their motor endowments; for the feeble 
action of these organs is one of the first observed phenomena of shock. 
Some very interesting observations were made on this subject during the 
late war by Drs. Mitchell, Morehouse, and Keen, of Philadelphia, from which 
they infer that the medulla oblongata and the pneumogastric nerves are 
chiefly concerned in bringing about the cardiac and pulmonary conditions. 
But we must not stop here. The central factor in shock is not circumscribed 
by the limits of the medulla oblongata; it embraces a wider domain of the 
cerebro-spinal system, including those sections, with their communicating 
nerves, which preside over the secretions of the various organs, which ener- 
gize the muscles of animal life, and which affect both common sensibility and 
the special senses, all of which are functionally disturbed. Nor can the vas- 
cular phenomena be satisfactorily explained without including the centre 
of the entire vaso-motor system of nerves, whether that centre lie in the 
medulla or in some other part of the spinal cord. 
By associating together feebleness of the heart and paralysis of the walls 
of the blood-vessels, we can explain the accumulation of blood in the deep 
venous trunks. The slight fall of temperature which is so often observed in 
shock would seem to be due to the temporary arrest of tissue metamorphosis, 
occasioned by the defective innervation. 
Secondary or Remote Effects of Shock.-The evil consequences of shock do 
not always terminate with the disappearance of its symptoms. They maybe 
witnessed long after what seems to be a perfect recovery; while not a few 
complain of never being the same persons after escaping from the immediate 
consequences of an injury. The gravity of these alleged remote effects is 
often out of all proportion to the original injury. These sequels appear cither 
in the nervous or in the nutritive system. Under the former may be no- 
ticed muscular weakness, irregular or choreic movements, defective memory, 
and wakefulness. Tn one instance, a young man who had been very severely 
injured by falling between a platform and a passenger-car suffered greatly 
both in body and in mind from his inability to secure a protracted rest. The 
moment he fell into a sleep he was aroused in a fright with a start, under an 
impression that he was falling under the cars. The hallucination continued 
as long as he lived, and, I believe, hastened his death. Others, again, suffer 
from disturbances of the digestive organs, in consequence of which they 
become anaemic and lose flesh and strength. In some instances, persons SHOCK. 
381 
who have at some previous time sustained a severe injury die suddenly, and 
their death is referred to traumatic cause. I will not deny that in many of 
these cases there is really a connection between the injury and the evil com- 
plained of; but it must be apparent that there is large room for error on 
this point. 
Prognosis.-If, after the lapse of a few hours, the pulse begins to increase 
in force and becomes more regular, showing that the energy of the heart is 
returning,-if the ashy pallor leaves the face and the respiration is performed 
with greater freedom and fullness, now and then broken by a full-drawn sigh, 
the indications point to a favorable termination of the case. If to these 
signs there is added an improved temperature of the skin, with a disposition 
on the part of the patient to turn on the side, to draw up the limbs, or to 
change the posture in any way from that of the dorsal decubitus, the pros- 
pects of recovery are still more favorable. The supine position indicates ex- 
treme muscular weakness, and any change which a patient is able to make 
is an evidence of increased power. 
On the other hand, it may be said that the longer reaction is delayed the 
greater is the danger. Every hour after twenty-four tells against the patient. 
A very slight fall of the temperature below what is normal-even one or two 
degrees-is an omen of evil; and the same may be said when the temperature 
is materially increased. Few persons ever rally in whom the heat of the 
body falls to 96° or rises above 103°. 
When the reaction begins, should the temperature exceed 103° there is 
ground for anxiety, especially if the rise occurs after the lapse of thirty-six 
hours. Should there be, however, after the elevation, a steady decline of the 
heat to 98°, or the health standard, it argues a salutary tendency in the 
disease. 
Any concomitant injury to the abdominal viscera, or to the contents of the 
cranium, confers additional gravity on the case. The same is true when 
there is the further complication of hemorrhage; for there is added to the 
exhaustion from failure of nerve-power a depression from syncope. The 
existence of renal disease will also weigh against the recovery of a patient 
from shock. 
Post-mortem.-If the death from shock has been sudden, the heart is some- 
times found almost entirely empty, as though the last act of the organ had 
been one of spasmodic contraction. 
The opposite condition, however, is the more common, especially when 
death has been gradual in its approach, the right auricle and the right ven- 
tricle being found distended and filled with loose blood-clots. The intes- 
tines are also distended,-the result of defective innervation. If food has 
been taken a short time before the occurrence of shock, it will be found un- 
changed in the stomach, digestion having been entirely suspended. If the 
patient has urinated a short time before the accident, the bladder will con- 
tain a very small amount of urine. The engorgement of the deep venous 
trunks usually witnessed follows from the failure of power at the centre of 
the circulation. 
Modes of death.-There are, consequently, four modes of death from shock : 
first, by a complete or total suspension of innervation, in which death is 
instantaneous; second, by exhaustion, following upon a partial or incomplete 
suspension of nerve-force, the fatal termination coming on gradually; third, 
by the loss of nerve-force and the loss of blood conjointly; and,/otzr?A, by 
exhaustion following excessive reaction. 
Treatment.-In very slight cases of shock, nature requires little if any 
assistance from the surgeon. The patient must be placed in the recumbent 
position, with the head low; and a little strong coffee may be administered, or 
some diffusible stimulant, such as the carbonate of ammonia. The depression 
is evanescent, and passes quickly over, leaving the patient unharmed. 
Not so, however, with those cases in which the symptoms are well pro- 382 
SHOCK. 
nounced. Such demand the most judicious attention. The immediate danger 
consists in the failure of the heart-action, and this must be counteracted by 
the use of such agents as will sustain the power of this organ. With this 
object in view, stimulants are generally administered, and often poured reck- 
lessly into the stomach. It must be remembered that the function of ab- 
sorption in that organ is almost wholly suspended in severe shock; and if 
stimulants are then given in large quantities they may accumulate, and work 
great harm when reaction does take place, by lashing the heart into action so 
violent as to induce a secondary depression more dangerous than the first. 
Fortunately for the patient, they are often thrown off by the vomiting which 
so frequently attends shock. 
In my judgment, stimulants are utterly useless during the early stage of 
shock. The time for their administration is when the signs of reaction begin 
to appear. They are then absorbed, and, if cautiously used, will give to the 
heart a timely aid, preventing that fatal relapse from cardiac exhaustion which 
often occurs. Brandy and whisky are the best, and should be given in small 
quantities, not exceeding a teaspoonful at a time, and at intervals of twenty- 
five minutes or half an hour. If the patient cannot swallow, they may be 
administered by the bowel. Stimulants act promptly, in cases of shock, 
when used hypodermically. Half a teaspoonful of good brandy may be 
introduced into the subcutaneous cellular tissue at several points with the 
hypodermic syringe, and this operation may be repeated according to the 
urgency of the case. 
External warmth is of the utmost importance, and should take precedence 
of all other remedies. It should be addressed to the head, the body, and the 
extremities. A rubber bag partly filled with hot water, or towels wrung 
out of the same, may be applied to the head; bottles containing hot water, 
or heated bricks rolled in flannel cloths, should be placed along the spine, the 
sides of the body, and the limbs; while over the epigastrium may be placed 
with advantage a sinapism of mustard. Volatile substances, such as ammonia, 
may also be held to the nose, as a means of exciting the respiratory move- 
ment. Dr. Hunter, of this city, suggests placing the patient in a hot bath. 
Nourishment, in the form of milk, hot coffee, or warm beef-essence, may 
be given in small quantities whenever reaction begins and the stomach will 
tolerate its presence. When the patient has lost much blood, this becomes 
a very important part of the treatment. 
In extreme cases of shock, where the respiration of the patient is fast 
failing, everything depends on maintaining the action of the heart. To this 
end artificial breathing must be diligently and persistently practiced. 
As the venous engorgement on the right side of the heart, so commonly 
seen in cases of collapse, resists the contraction of the right ventricle and 
auricle, and enhances the danger, Mr. Savory has advised the abstraction of 
blood in order to relieve the over-distended organ. The suggestion is a 
rational one when there has been no precedent hemorrhage and the condition 
can be clearly determined. Distention of the superficial veins of the neck is 
the sign of this venous engorgement, and, when present, the external jugular 
may be opened. 
In cases where the depression is deepened by the loss of blood, transfusion 
is well worthy of trial. 
As soon as the symptoms of reaction arc well pronounced, there should 
be a halt in the use of stimulants. The continuance of their use beyond this is 
calculated to do a great deal of harm in the treatment of shock, and perhaps 
causes the loss of more lives than they save. Whenever, therefore, the pulse, 
the temperature, and the color begin to improve, nourishment, if the stomach 
will retain it, is of infinitely more importance than stimulants. The latter, 
it will be perceived, have their true application during that short period 
which intervenes between the first dawn of reaction and its near completion. 
The indications now are to lessen excessive action and sustain power. For 
this object our most valuable resource is opium with digitalis. Twenty-five SHOCK. 
383 
or thirty drops of laudanum with ten drops of digitalis may be given by the 
mouth. Or, if the stomach proves to be irritable, a suppository, consisting 
of two grains of opium with the same amount of hyoscyamus, should be 
introduced into the rectum; or a quarter of a grain of morphia may be ad- 
ministered hypodermically. 
When the reaction is accompanied or followed by any of the forms of 
delirium which have been described, the anodyne treatment is still more im- 
peratively required; and, in addition, an ice-bag may be applied for a short 
time to the head. 
The irritability of the stomach sometimes becomes so prominent a symptom 
after reaction as to demand special attention. To allay this irritability, a 
tablespoonful of mint-water, containing half a drop of carbolic acid and half 
a drop of dilute hydrocyanic acid, should be given, and a mustard-plaster 
placed over the epigastrium. Small pieces of ice placed in the mouth and 
allowed to dissolve are very efficacious in allaying the thirst from which 
the patient suffers. When the delirium is of such a nature as to render it 
necessary to employ restraint, the wrists and ankles of the patient should 
be made secure to the bed by roller bandages, if the more elaborate hospital 
appareil is not at band. 
In those cases in which collapse and reaction are contending for the 
mastery,-that is, where reaction has become measurably established and 
then recedes,-the surgeon must not be too anxious to interfere. He had 
better become an attentive spectator, and take sides only when the enemy 
seems to have the vantage-ground. 
Operations during the Existence of Shock.-The propriety of per- 
forming an operation during the condition of shock is a subject which 
requires the most cautious consideration. 
There can be no objection to adjusting a broken limb, the malposition of 
which must, by causing pain, add to the severity of the shock. Nor would 
it be wrong to control the hemorrhage of a wound, even if in doing so it 
became necessary to cut down upon and expose a large arterial trunk. The 
collapse which sometimes follows incipient strangulation of an intestine can 
be no bar to performing an operation for the relief of hernia, as only by so 
doing can we hope to remove the shock. The same may be affirmed with 
regard to a compound depressed fracture of the skull with shock: the bone 
should be elevated as an essential part of the removal of collapse. 
With reference, however, to the performance of an amputation, or to the 
excision of a joint after a compound luxation, the course to be pursued is some- 
what different. To operate when there are no evidences of reaction from 
the collapse is to add injury to injury; and until reaction takes place, as a 
general rule, the knife must be withheld. 
There are some who think that in prolonged shock, rather than allow the 
case to pass beyond the limits of the primary period, it is better to operate, 
even during imperfect reaction, especially as the patient may be spared all 
pain by the use of an anaesthetic. 
There can be little doubt of the correctness of this opinion. The ether 
does more in such cases than prevent pain : it really imparts tone to the heart, 
and favors rather than retards the progress of reaction. The great point in 
these cases is that the surgeon shall have a reasonably well-grounded as- 
surance that what reaction does exist is sufficient to withstand the effects of 
the operation which he is about to perform. 
Traumatic Infective Fever. 
It is often difficult to invent terms which will convey exact ideas of path- 
ological conditions. Under the head of traumatic infective fever I shall treat 
of fever following injuries and operations, and which I believe to be due to 
the introduction into the blood of certain subtle septic matters which are the 
products of tissue-decomposition. Among the various names which have 384 
TRAUMATIC FEVER. 
been given to the morbid phenomena may be mentioned phlebitis, pyaemia, 
pyohaemia, septhaemia, septicaemia, septaemia, septopyaemia, ichorhaemia, pur- 
ulent absorption, pyogenic diathesis, metastatic or multiple abscess, throm- 
bosis, surgical fever, surgical typhus, and suppurative fever. 
Simple Traumatic Infective Fever.-In all cases of any considerable opera- 
tion or injury, after the lapse of from eight to thirty-six hours the patient 
presents the phenomena of fever, which has been designated " wound fever" 
" surgical fever," and "traumatic fever." It is sometimes ushered in by a 
short period of restlessness. The patient complains of being hot, the face 
becomes flushed, the skin is dry, and these symptoms are accompanied with 
thirst, loss of appetite, and not unfrequently headache. The tongue is also 
coated, and the pulse is increased in frequency ovex- the natural standard. 
Should the febrile excitement run high, there may be some confusion of 
the intellect, with slight delirium. The secretions are usually disturbed, 
the mouth being dry, the bowels costive, and the urine scanty and high- 
colored. Not unfrequently the febrile symptoms are inaugurated by a rigor 
ox* chill. Should the fever continue fox* any considerable time, it assumes an 
intermittent type, with regular morning and evening exacerbations. Usually, 
however, in a short time, varying from a few hours to two or three days, the 
fever begins to subside, the pulse is lessened in frequency, the temperature 
falls, the thirst abates, the secretions return to the mouth, the skin is covered 
with a gentle moisture, and the urine becomes more abundant, furnishing a 
free deposit of urates. 
The temperature rarely exceeds 102° or 103°; though I have seen it as high 
as 105°. 
The intensity of the fever is usually in proportion to the severity of the 
injury. A large allowance, however, must be made for constitutional pecu- 
liarities. There are many persons who, on the reception of very slight 
injuries, experience high constitutional disturbance, while others, of a more 
phlegmatic and gross organization, endure severe injuries or operations with 
comparatively little disturbance of the circulation. 
The causes of surgical infective fever must be sought foi- in the wound, or 
at the seat of injury. It is true that the shock sustained by the system may 
exist in some degree as an element in causing the subsequent excitement. 
But when it is remembered that, even after wounds or injuries so slight as 
to cause no depression, nervous or circulatory, severe febrile symptoms may 
ensue, it must be evident that this condition can play but a very subordinate 
role in causing the fever. Very soon after an individual has suffered from 
traumatic violence, important changes set in at the seat of injury. The 
vitality of the damaged tissues is destroyed to some extent, and these de- 
vitalized fragments undergo decomposition, while around them there is 
taking place the rapid tissue-change incident to an inflammatory process. 
The products of these chemical and physiological actions, intermingled with 
the blood serum which flows into the parts about the wound, must be disposed 
of. A portion will escape through the wound, and, when the lattei' commu- 
nicates with the surface, will be imbibed by the dressings. Another portion 
enters the veins, and probably also the lymphatics, and is in this way turned 
into the blood-vessels. The admixture of this sewage with the blood so 
alters the quality of the latter that it becomes an irritant to the cardiac gan- 
glia, thereby exciting the heart-action; and the rapid interchange of tissue, 
referable to the inflammation, is attended with the production of an unusual 
amount of heat, which explains the high temperature. 
Treatment.-During the period of traumatic fever the symptoms will be 
moderated by the use of refrigerants, such as the neutral mixture, containing 
a very small amount of morphia, or by administering from time to time some 
sweet spirit of nitre. Cold drinks will also prove both grateful and valuable; 
and, while it is not necessary to purge the patient, the bowels should not be 
allowed to remain constipated. After the disappearance of the fever, the TRAUMATIC FEVER. 
385 
system is left in a feeble, depressed state, demanding the use of a good diet, 
tonics, and stimulants. 
Secondary Traumatic Fever.-A patient may pass through the usual dis- 
turbance of surgical fever and all the symptoms quietly disappear, and yet, 
a few days later, he may have a renewal of the attack. An occurrence of 
this nature should be always regarded with anxiety. It is often ushered 
in by a chill, and is frequently the outcome of an inflammatory invasion of 
some part or organ of the body. It may be an abscess situated in the cellular 
tissue, more or less remote from the seat of operation, or it may be caused 
by the involvement of some portion of the thoracic or abdominal viscera. If 
the fever continues for several consecutive days without abatement, and there 
is a recurrence of chills, great apprehension for the safety of the patient 
may be entertained. The most rigid examination and interrogation of every 
organ should be instituted, in order to ascertain the location of the disease; 
and, when it has been traced to its proper source, the treatment must be 
conducted on general principles applicable to the case. 
Should the febrile paroxysm assume an intermittent type, it may be re- 
ferred to miasmatic influences which have remained dormant in the system 
and have been called into activity by traumatic shock. This is especially 
likely to be true if previous to the operation the patient has been exposed 
to the atmosphere of unhealthy localities. Full doses of quinia will generally 
suffice to break up the fever and establish convalescence. 
This secondary fever may partake of the nature of hectic, and seriously 
complicate the success of an operation. It may be developed by a profuse 
or tedious suppuration, or by a phlegmasia of the pulmonary or renal organs. 
The efforts of the surgeon under these circumstances must be directed 
to the support of the system by food, tonics, and stimulants, and, when the 
suppuration is external, by adopting such measures as will arrest the forma- 
tion of pus, secure the consolidation of the parts, and, by establishing the 
most perfect drainage, prevent purulent infiltration. 
Complicated Traumatic Infective Fever.-In this variety of the disease, 
in addition to an adynamic type of fever there are present various inflam- 
matory changes of a secondary nature in different organs and tissues of the 
body, in the form of multiple abscesses and sero-purulent formations in the 
serous and synovial cavities. The terms pyiemia and septicaemia are generally 
employed to express this type of surgical fever. 
The term pyaemia, derived from two Greek words, 11 pus," and di/za, 
" blood," originated with Piorry, a French physician, and signifies pus in the 
blood. Allusions to the disease may be found in several of the older surgical 
writers, among them Ambrose Pare and Guthrie, who had observed a similar 
relation between a certain class of wounds and abscess of the spleen. It is 
only, however, of late years that anything approaching the true pathology 
of this complicated traumatic infective fever has been ascertained. For this 
knowledge we are chiefly indebted to the labors of our French and German 
brethren, and, among the latter, notably to Virchow. 
For the solution of this pysemic problem several theories have been pro- 
pounded. These may be classified as the purulent, the thrombotic or embolic, 
the miasmatic, and the septiccemic. 
Purulent.-By the purulent theory is meant the theory which attributes 
the fever to the introduction of pus into the blood. In considering this 
theory, two questions arise,-what are the routes by which pus can enter the 
circulation, and what effect is produced on the general system by the ad- 
mixture of pus and blood? There are three ways by which it would appear 
that pus can enter the circulation, viz., by the veins, by the lymphatics, and 
by the arteries. 
(1) Entrance by the veins.-It is after operations in which these vessels are 
divided that this intrusion is said to take place. The conditions for such ad- 
vol. ii.-25 386 
TRAUMATIC FEVER. 
mission, if it ever does occur, are most favorable in injuries or wounds which 
open the cancellated tissue of bones, and where, in consequence of the size of 
the venous trunks and their surrounding connections, the complete collapse 
of their walls is prevented. The very common occurrence of pyaemic symp- 
toms after such injuries is apparently corroborative of this view: I say ap- 
parently, since there are no facts which raise this statement above the region 
of conjecture. I cannot believe that pus, as such, reaches the circulation in 
this manner. After the division of a vein, its walls, particularly when sur- 
rounded with soft parts, fall together, and are soon closed by a clot or by 
adhesive inflammation, either of which would offer an impenetrable barrier 
to the intrusion of pus-cells. There is, moreover, no circulation in that part 
of the vein which is in nearest relation to the wound. 
An abscess may form in some portion of the body, or a wound may be 
inflicted, and, from inflammatory adhesion, the walls of the one or the sides 
of the other may become united to a contiguous vein. Ulceration may sub- 
sequently set in and form a communication between the two, and in this 
way pus may pass directly into the venous current. I have seen an abscess 
of the arm open into the cephalic vein after this manner. 
Another way in which pus was thought to enter the veins was by phle- 
bitis,-a doctrine which was warmly espoused by John Hunter, Guthrie, Aber- 
nethy, and Liston. This was also the theory of Dance, based by him on 
what he had observed in uterine phlebitis occurring in puerperal women. It 
received the support of Cruveilhier, and was more thoroughly elaborated by 
this investigator and by Blundin. The objections which may be urged against 
this theory are the want of uniformity in the position of the inflammatory 
products (being oftener external to the inner tunic of the vein than within the 
latter, or, if within the vessel, being incarcerated in the midst of the coagulum 
which succeeds the phlebitis), and the fact that the pyaemic condition may 
exist independent of any inflammation of the veins whatever. 
(2) Entrance by the lymphatics.-Another system of vessels communicating 
with the circulation is the lymphatic. These are necessarily opened in oper- 
ations, in the same manner as the veins, or they may themselves become the 
subjects of suppurative inflammation,-in either event offering an avenue for 
pus. But it is exceedingly improbable that pus can ever reach the blood-stream 
through these channels. The lymphatics, on their way to the thoracic duct, 
do not pass through the lymph-glands, but terminate in them. These glands 
are known to arrest substances of smaller dimensions than the pus-corpuscle, 
-e.g., the finest particles of coloring-matter. Indeed, one of the offices of the 
lymphatic glands is to intercept substances which are calculated to prove 
prejudicial to the body should they reach the circulation. 
(3) Entrance by the arteries.-The third route for the entrance of pus into 
the blood is through the arteries. This may occur by ulceration of their 
walls. The thoracic aorta may be the subject of aneurismal dilatation, and, 
by its pulsation, excite inflammation and partial absorption of the vertebra? 
against which it rests. The irregular or spiculated fragments resulting from 
these changes in the bones may cause ulceration in the walls of the vessels, 
and thus open a way for the entrance of pus. Or the same thing may follow 
upon a suppurative arteritis, the purulent matter finding its way into the 
cavity of the vessel. 
Velpeau and others have attributed the pyaemic phenomena to the absorp- 
tion of pus. But there is no evidence, physiological or pathological, to sus- 
tain such an inference. Pus, as such, is never absorbed. It is true that in 
some instances the contents of an abscess may disappear without being dis- 
charged externally, and the development of hectic symptoms as the result of 
suppuration is a familiar event. But in neither case does the pus-cell enter 
the blood. Before the pus-cell can be absorbed, it is necessary that it shall 
undergo a transformation by which both its form and its chemical character- 
istics are materially changed. 
The unity of the pus-corpuscle and the leucocyte is the accepted doctrine TRAUMATIC FEVER. 
387 
of the present day; and it may be said that a body whose native habitat is 
the vessel, on escaping, could not exert a poisonous effect when returned again 
to the blood. This, however, is not a fair deduction from the premises, as 
it cannot be supposed that after migration the pus-cell, however recent, 
continues to retain the same physical and chemical constitution that it had 
before it left the vessel. 
The argument in support of the purulent theory, drawn from the presence 
of pus in the blood of patients who have died from the form of infective fever 
under consideration, is also open to the serious objections that no distinction 
can be made between the two corpuscles, and that the bodies noticed in such 
large numbers in the blood of pyeemic patients, and affirmed by many to be 
pus-corpuscles, are probably, as stated by Virchow, leucocytes, which have 
been greatly multiplied by the irritation of the lymphatic glands, the con- 
dition answering to the leucocythamiia of Bennet. 
Effects of Pus in the Blood.-In order to determine the effect of intro- 
ducing pus into the circulation by artificial means, numerous experiments 
have been instituted by different observers, among whom may be mentioned 
Gaspard, Magendie, Sedillot, Polli, and Callender. The results varied in 
different experiments. 
Generally, when fresh pus was thrown into the veins of healthy dogs, the 
animals, though exhibiting symptoms of constitutional disturbance, recovered 
after a few days of indisposition. The repetition of these injections, how- 
ever, or the introduction of a considerable quantity of putrid pus into the 
blood, usually caused the death of the animals. 
The anatomical appearances which were noticed consisted sometimes in 
the formation of soft clots; in other instances the blood was found separated 
into its different components and disorganized. Secondary deposits, or ab- 
scesses, were frequently seen in the venous capillaries of the lungs, together 
with gastro-intestinal symptoms. 
Other experiments were performed by injecting liquid infusions of different 
putrid substances, both animal and vegetable, with results not differing 
materially from those obtained when pus was introduced. 
It should be noted that in the so-called pyaemia there are two distinct 
factors, a local and a general one. The first is seen in the secondary deposits, 
or metastatic abscesses, which form in the pulmonary, hepatic, and other cap- 
illaries, and which are considered by many to be the result of obstruction, 
while the second is expressed by the toxic symptoms characterizing infective 
fever. It is essential to the proper study of this subject that these two condi- 
tions be kept clearly in mind. Berard, in his paper on purulent infection and 
putrid infection, had evidently this distinction in view; and the same is true 
of those who distinguish between pyaemia and septicaemia. Pus, in its chem- 
ical constitution, is an exceedingly complex substance, containing a large 
amount of organic matter. The products of decomposition, such as ammonia, 
sulphuretted hydrogen, butyric acid, tyrosin, and other substances, when in- 
troduced into the circulation, cannot fail to produce serious alterations of the 
blood. It is by no means proved that the solid portion of pus becomes aggre- 
gated so as to blockade the capillaries and excite a local suppurative inflam- 
mation, occasioning the multiple or secondary abscesses. The septic materials 
resulting from the decomposition of its less stable constituents, being diffused 
through the whole mass of the blood, will unquestionably not only develop 
a putrid fever, but may produce also the local phenomena. 
Thrombosis and Embolism.-This is the doctrine of Virchow, and one 
which has been accepted by the most prominent German pathologists. It 
has been enunciated in a less formal manner by Darcet, of France. Throm- 
bosis or coagulation of the blood may be determined by various causes, 
among which may be mentioned change in the constitution of the blood,, 
phlebitis, roughness or irregularities on the inner surface of the vessel, and 
retardation of the blood-stream. 
By change in the constitution of the blood are meant such alterations as are 388 
TRAUMATIC FEVER. 
induced by the introduction of septic substances into the vessels, by the 
separation of the fibrin with the albumen from the other constituents of 
the fluid, and their deposition on some portion or portions of the lining mem- 
brane of the vessels. If fibrin, as alleged by Schmidt, does not normally 
exist in circulating blood, this latter explanation must be abandoned; though 
Schmidt's hypothesis does not exclude the idea of coagulation by the catalytic 
influence of some ferment which is present. 
In thrombosis, attended by symptoms of inflammation, it is not always 
possible to say exactly how the two processes are related to each other,- 
that is, whether the phlebitis determined the coagulation, or the coagulation 
caused the phlebitis,-as both, undoubtedly, do in many instances occur. 
The thrombosis, however, which is so peculiarly related to pyaemia is that 
which is due to an antecedent wound. The formation of a clot in the saphena 
vein is not an uncommon occurrence in typhoid, scarlatina, and other fevers 
in which the blood has been profoundly altered; yet pyaemia as a conse- 
quence of such coagula is almost unknown. Embolism of arteries frequently 
takes place, and may be followed by gangrene in the parts belonging to the 
distribution of the obstructed vessel, but not, generally, by the signs of puru- 
lent infection. 
The theory of thrombosis is, that a clot of blood forms from some cause in a 
vessel, for example, a vein. This clot may increase by additional deposits 
until it rises to a point on a level with, or even above, that where a col- 
lateral branch enters the obstructed vessel. The blood-stream, as it passes 
along, detaches a portion of the clot,,or the coagulum spontaneously begins 
to disintegrate, and the fragments are borne onward in the current to the right 
side of the heart, and finally through the pulmonary artery to the venous 
capillaries of the lungs. Some of these fragments are arrested in capillaries 
of the first order, while others-particles of smaller dimensions-may slip by 
into those of still smaller size. The presence of these foreign bodies, blocking 
up the vessels, provokes a suppurative inflammation within the territorial 
limits of the obstructed capillary, forming what are called secondary deposits 
or multiple abscesses. 
There is, however, a pathological fact known to exist in the disease under 
consideration, which is not satisfactorily explained by the theory of embolism, 
except by admitting that there may be embolic particles so exceedingly small 
as to pass through the pulmonary capillaries. I refer to the absence in some 
cases of pyaemia of any secondary deposits in the pulmonary capillaries, while 
at the same time they are present in other viscera, as the liver and the spleen. 
Weber admits this passage for certain portions of pus, and I can conceive of 
no insuperable objection, based either on the divisibility of matter or on the 
anatomy of the capillaries, to allowing a similar passage of a fragment of 
clot from the venous to the arterial system. The untenability of the ex- 
planation lies in this, that it seems incredible, on the above theory, that all 
the embolic fragments (for there must be many) should be so infinitely small 
as to pass from the pulmonary arteries to the pulmonary veins. 
Miasmatic Origin.-The advocates of the miasmatic origin of pyaemia, I 
presume, mean the presence in the air of certain septic materials, which, 
when brought into contact with an open suppurating wound, are competent 
to cause systemic infection. The dust which floats in the atmosphere of a 
filthy and badly-ventilated hospital ward in which are many suppurating 
sores may acquire very dangerous qualities from being charged with the 
products of decomposition. The propagation of hospital gangrene through 
the medium of the air needs no confirmation in the light of present ex- 
perience. 
It is even supposed that intangible poisons or miasms may find their way 
into the blood through the lungs and develop signs of purulent infection. 
But, if this be true, it may be queried, why should not some persons without 
wounds, who breathe the same air, suffer alike with those who have suppu- 
rating sores? In cases where persons are suffering from suppurating injuries TRAUMATIC FEVER. 
389 
of either the bones or the soft parts, it is not unreasonable to suppose that 
the inflammatory products may be increasingly vitiated by the operation of 
subtle poisons which are capable of disturbing a proper blood-formation, by 
acting on the blood and rendering it unfit for the purpose of repair or for 
the nutrition of tissues. In no other way do I suppose that miasmata can 
exercise through the lungs any influence in originating pyaemia. 
Septicaemia.-The fourth theory for the production of complicated trau- 
matic infective fever is that of septicaemia; that is, the introduction into the 
circulation of some subtle, intangible septic poison, the product of putrefactive 
changes in the solids and fluids of the damaged parts, so modifying the blood 
as to favor the formation in the capillaries of obstructive coagula, which, 
acting as irritants, originate foci of suppurative inflammation, or multiple 
abscesses, and diffuse inflammations both in serous and synovial membranes. 
This is the only theory that is adequate to account for all the phenomena of 
pyaemia. 
The whole subject of traumatic infective fever may, therefore, be formu- 
lated as follows: first, a general disturbance of the system, as expressed by 
the symptoms of fever; second, the occurrence of local and diffuse inflam- 
mation, followed by multiple abscesses, and by sero-purulent transudations 
into the serous and synovial cavities. 
Morbid Anatomy.-An examination of the bodies of those dying from trau- 
matic infective fever reveals very extensive and wide-spread alterations of 
structure, the most notable of which are numerous abscesses in different 
organs and tissues of the body, and, not unfrequently, accumulations of 
purulent fluids in the serous cavities and in the joints. 
Lungs.-These points of suppuration, multiple or metastatic abscesses and 
secondary deposits, as they are called, are most frequently met with in the 
lungs, and, according to Callender, oftener in the left than in the right lung. 
They may be few in number, or they may amount to many hundreds, and 
are seen of all sizes, from the size of a millet-seed to that of a walnut, and 
in every part of the organ, especially in the posterior part of the lower 
lobes of the lung. These nodules vary in color, which depends in a great 
measure on their age. They may be red or reddish brown, gray, yellow, 
or dark brown,-shades which are significant of the inflammatory stages 
through which the patches are passing, in most respects answering to the 
red and gray hepatization, suppuration, and gangrene observed in the course 
of a pneumonia. In truth, the disease is one of circumscribed or lobular 
pneumonia. When laid open, they are found to consist of a cavity formed 
at the expense of the parenchyma of the lung, and containing pus, together 
with minute fragments of disorganized pulmonary tissue. Some of these 
patches, when cut into, appeal' to be of comparatively recent formation, as 
they contain a very small amount of pus with considerable granular matter. 
When the nodules present a very red appearance, they form the so-called red 
infarctions. Secondary pleurisy is often present, and is most probably induced 
by a propagation of inflammation from these patches of multiple abscesses, 
which lie near the surface of the lungs. The pulmonary organs, from their 
relation to the venous system, are much more frequently the subjects of in- 
farctions abscesses than the other internal organs; according to Sedillot, 
ninety-nine times in a hundred cases of the disease. 
Liver.-The liver suffers next in frequency to the lungs. Discolored spots 
-generally dark red-may be seen scattered through the organ. The in- 
flammatory patches undergo softening much more rapidly than those of the 
lungs; and indeed the hepatic tissue for some distance beyond the limits of 
the abscesses is abnormally red, soft, and friable. About 25 per cent, of the 
cases of traumatic infective fever implicate the liver. The uniform connec- 
tion between suppuration of this organ and injuries of the bead, of which so 
much has been said, I have never observed. 
Spleen.-This organ is uniformly enlarged, and is altered in both form and 390 
TRAUMATIC FEVER. 
consistence; and when it is the subject of secondary deposits it presents in- 
durated masses or nodules of an oblong or cuneiform shape, which, when 
opened, are seen to be abscesses. Each abscess is surrounded by a vascular 
zone. Nor is the structural alteration confined to the neighborhood of these 
deposits of pus; indeed, the entire gland, as well as its pulp, is softened and 
easily broken down under pressure. 
Kidneys.-The renal organs are affected in the same manner as the lungs 
and liver, though not with the same frequency. Numerous patches of sup- 
puration are met with through the substance of these organs, each being 
invested with a circle of congested blood-vessels. When the disease follows 
an operation on the genito-urinary organs (for example, that of lithotomy or 
of perineal section), these organs are particularly prone to the formation of 
abscesses. 
The prostate and testes are not exempt from similar inflammatory changes, 
though the latter are much less common in these parts than in the lungs 
and liver. 
Heart and brain.-The heart and brain occasionally suffer in common with 
the other organs, exhibiting spots of local inflammation, with suppuration 
situated near the surfaces, or immediately beneath their serous coverings. 
It may readily be supposed that inflammatory changes situated in the 
peripheral portions of organs may easily extend to the membranes which 
surround the same; and hence pleuritis, peritonitis, pericarditis, and arach- 
nitis in numerous instances follow in the course of the disease with purulent 
formations in their cavities. 
Joints.-Continuity or proximity of structure will not, however, explain 
the purulent transudations met with in joints. We must, therefore, refer 
these cases of synovitis to the state of the blood. Bryant has noticed a 
singular preference of the disease for the sterno-clavicular articulation. In 
my own experience the ankle or the knee has most frequently suffered. The 
morbid changes which are noticed in joint complications accompanying the 
fever are opacity of the synovial membrane, increase of its secretion, the 
presence of unhealthy pus, the loss of the pearly, glistening appearance of 
the articular and interarticular cartilages, and, occasionally, even the disor- 
ganization of the latter, with caries of the underlying ends of the bones. 
Nor are these inflammatory transudations confined to the internal organs 
and to the serous and synovial membranes alone. They are seen in the skin, 
in the subcutaneous tissues, and in the midst of the muscles, lymphatics, blood- 
vessels, thyroid gland, and tongue. 
These purulent collections which are found in the muscles present gener- 
ally the characteristics of laudable pus, without any infiltration or surround- 
ing vascularity, such as belongs to an ordinary acute abscess, or even to those 
abscesses which have been described as existing in the internal organs. 
Eruptions of a pustular character, and hemorrhagic patches, with purple 
discolorations, appear on different portions of the body and the limbs. Jaun- 
dice, to a greater or less degree, is quite a common occurrence, depending 
probably on some structural alteration of the liver. 
Not only does the entrance of septic matter into the lymphatics excite 
inflammation of these vessels, but, as their contents are poured into the 
lymph-glands, the poisonous material may there be detained and give rise 
to a suppurative adenitis. It is the irritation of these glands which, according 
to some writers, accounts for the multiplication of leucocytes seen in the 
blood in this fever, and which were once supposed to be pus-corpuscles. 
When there have been gastro-intestinal or intestinal symptoms present, both 
the agminated and the solitary glands are found congested and swollen. 
Inflammation of the veins is not very common in complicated traumatic in- 
fective fever, notwithstanding the prominence once given to phlebitis as the 
radical element in pytemia. When it does exist, the walls of the inflamed 
vessel become thickened by infiltration and its cavity obstructed with coagula, 
-a result, not a cause, of the disease. TRAUMATIC FEVER. 
391 
Little can be learned from an examination of the blood of pysemic pa- 
tients. The most searching chemical and microscopic observations tail to 
detect anything which can be identified as the disturbing agent. The rela- 
tion which minute organisms, like bacteria, found in the blood of infected 
persons bear to the change in the constitution of that fluid is mere matter of 
conjecture. The property of coagulation, though not lost, is certainly lessened, 
and the color of the venous blood appears to be considerably darker. In a 
few instances patients die of complicated traumatic infective fever in two or 
three days from the commencement of the attack, and when the autopsy is 
made there are no morbid appearances found adequate to explain the cause of 
death. In such cases it is not unreasonable to infer that the virulence of the 
poison induces such disorganization or alteration in the constitution of the 
blood as to cause an arrest in those tissue-interchanges which belong to 
healthy nutrition. But, in truth, nothing definite is known on the subject. 
Mr. Savory and others believe that the disease may arrive without any pre- 
vious traumatic history (idiopathic pyaemia, as it has been called); but that is 
entirely at variance with my own observation. 
Predisposing Causes of complicated traumatic infective fever are numerous. 
Among these may be mentioned severe shock, excessive loss of blood, imper- 
fect drainage of a wound, disease of the kidneys, and imperfectly ventilated 
or overcrowded apartments, especially where the occupants are suffering from 
open wounds. Persons who receive an injury during convalescence from 
some exhausting malady, or who are suffering from erysipelas or gangrene, 
are vulnerable subjects for the disease; and the same is true of women during 
the puerperal state. Operations or injuries which open the cancellated tissue 
of bones leave the patient greatly exposed to the risks of pyaemia. 
Symptoms.-The development of this disease is sometimes foreshadowed 
by local changes. A suppurating wound which may have been progressing 
favorably suddenly becomes dry, glazed, and inflamed ; or it may discharge 
a vitiated pus, the surrounding parts being swollen, cedematous, and often so 
painful as to cause great suffering on the slightest movement. This condition 
rarely occurs earlier than the eighth or twelfth day after the reception of 
the injury. In other instances the signs of the constitutional infection are 
manifested without anything peculiar or unusual being observed about the 
wound. The patient becomes despondent, lapsing into a drowsy, stupid con- 
dition. The skin is sometimes hot and dry, the mouth parched, the tongue 
hard and crisp, the urinary secretions greatly diminished in quantity, and 
often the stools are frequent, watery, and offensive. The fever which accom- 
panies the above symptoms is markedly persistent, though the temperature 
may not rise very much above the normal standard. So long as secondary 
deposits or abscesses do not form, it is possible that the invasion of the febrile 
phenomena may neither be preceded nor followed by well-marked chills, 
except when an erysipelatous blush makes its appearance. Then a rigor 
will invariably occur with an elevated temperature. As the disease advances, 
the pulse becomes more feeble and frequent; the skin presents a dirty, pale, 
sallow color, with an icterode hue of the conjunctiva; the body emaciates; 
the temperature falls; and the patient dies in a state of collapse. Cases of 
this kind may run a fatal course in seven or eight days, or they may linger 
for two or three weeks; and in rare instances the patient may finally 
recover. 
In Fig. 1233 there are recorded the thermometry, circulation, and respira- 
tion of a patient who presented the symptoms of septicaemia following a severe 
injury of the hand and arm, attended with diffuse suppuration, and who 
finally recovered. The diurnal variations of temperature, and its influence 
on the action of the heart and on the respiration, are well shown ; also the 
steady decline of bodily heat coincident with defervescence and convalescence. 
In other cases, the earliest recognized symptom is a chill or rigor, pre- 
ceded and followed by a sudden elevation of temperature,-the ther- 
mometer rising in some instances, during the fever stage, as high as 104° 392 
TRAUMATIC FEVER. 
or even 107°, and liable to constant variations. The chill may be of very 
short duration, lasting only a few minntes, or it may continue for half an 
Fig. 1233. 
Fever, circulatory, and respiratory chart, from a case of complicated infective fever; the letter c indicates a chill. 
hour, and it is more likely to occur during the day than in the night. But, 
however brief, it leaves the deepest traces of the evil which has been done 
to the system. An oppressive sense of weakness is experienced. The fea- 
tures are pinched and the brows knit, while the countenance wears a sad 
and anxious expression. The rigor is succeeded by fever. The pulse is feeble 
and very frequent, beating from 130 to 160 times a minute, the skin is in- 
tensely hot and dry, there is great thirst, and the respiration is more or less 
hurried. 
Following these symptoms comes the sweating stage. The sweat begins 
first as a gentle moisture, but rapidly ends in a profuse, dripping perspiration, 
during which the temperature falls and the arterial excitement subsides, thus 
terminating the first paroxysm of the infection. It is the announcement of 
serious mischief. Both physician and patient now feel that a deadly blow 
has been inflicted. 
The fever chart on the following page (Fig. 1234), which records the tem- 
perature and circulation of a fatal case of pyaemia following an amputation 
of the thigh performed for necrosis the result of a gunshot wound, will con- 
vey an accurate idea of the thermometric fluctuations, and the relation of the 
latter to chills and to the circulation. 
These rigors recur at irregular intervals. Generally, after the first one, the 
patient is free from a repetition for two or three days, after which they may 
take place as often as two or three times in twenty-four hours. Occasionally 
they are repeated with the regularity of an intermittent. As the disease 
progresses, the pulse becomes increasingly frequent and feeble; the tongue 
is covered with a dark brown coat; the secretion of urine is scanty, some- 
times albuminous, and emits an offensive, ammoniacal odor; the abdomen 
may be distended or retracted. At one time there may be diarrhoea, at another TRAUMATIC FEVER. 
393 
constipation; and not unfrequently the patient is harassed with nausea and 
vomiting. 
The fatal tendency of the case is still further indicated by the increasing 
Fig. 1234. 
Fever chart in a case of pyaemia. 
debility, the emaciation, the ominous flush on the cheek, the dusky or jaun- 
diced color of the face, and the sordes which adheres to the teeth and lips. 
The nervous system partakes of the general decay of the body, as ex- 
hibited in tremulousness, subsultus tendinum, stupor, or muttering delirium. 
In some instances a hay-like odor can be detected on the breath of the 
patient, noticed by Berard and Gamgee. I remember one case of the disease 
-following an operation for stone-in which this peculiar odor was so distinct 
that I called the attention of the medical attendant to its presence before 
entering the room of the patient. 
When secondary deposits occur, the fact is often announced by painful 
swelling of the knee, ankle, or other joints, or by the rational signs of pneu- 
monia, as cough, severe pain, and bloody sputa. The pulmonary implication 
may sometimes be detected by the presence of the physical signs peculiar 
to lobular pneumonia. Still, the lung may contain innumerable congestive 
and suppurating foci without furnishing any evidence, rational or physical, 
of such lesions. The occurrence of pleurisy or pleuritic effusion may be 
regarded as significant of multiple abscesses in the lung, as generally such 
conditions are secondary to the pulmonary complication. 
The signs of secondary deposits in the liver are usually matters only of in- 
ference, founded on the frequency of their occurrence in this malady. But 394 
TRAUMATIC FEVER. 
undue sensibility to pressure or percussion over the right hypochondriac 
region will afford strong evidence that this organ has been invaded. 
Early cerebral symptoms, as delirium followed by stupor, are grounds for 
predicating the existence of secondary deposits in the brain. 
The period at which death takes place varies very much in different cases. 
Generally it is about the ninth or tenth day. In some instances the fatal 
event has followed in twenty-four hours after the attack, and in a few it has 
been postponed six or eight weeks. 
Diagnosis.-Usually it is not difficult to recognize complicated traumatic 
infective fever. The diseases to which it bears the strongest resemblance are 
ordinary or primary abscess, erysipelas, simple surgical fever, hectic fever, 
pneumonia, intermittent fever, and rheumatism. 
Primary abscess.-It is no uncommon event, after an operation, for a patient, 
at some period during the after-treatment, to have a slight chill, followed by 
an elevated temperature and some fever. Such phenomena are always calcu- 
lated to create alarm. But if, on examination, a tender point is discovered 
in the subcutaneous cellular tissue of some part of the body, with fluctuation, 
the symptoms may very confidently be referred to this superficial abscess; 
for the purulent formations attending infective fever do not primarily elect 
the subcutaneous tissue for their locations, nor is there a disposition in 
primary abscess either for the chills to repeat themselves or for a continuance 
of the fever. 
Erysipelas.-A very small patch of erysipelatous inflammation, occurring 
in the course of a surgical case, will be sufficient to create a rigor, followed 
by considerable vascular excitement. The presence of the characteristic 
blush, unattended with a repetition of the chills, will explain the disturbance 
as being, in all probability, independent of pyaemia. 
Simple surgical fever, sometimes called " inflammatory fever," is that constitu- 
tional disturbance which arises a short time after an operation, and which is 
the result of a slight blood-infection, but vanishes usually as soon as suppu- 
ration is established in the wound. It is by this latter circumstance that its 
true nature is recognized. 
Hectic fever bears a very strong resemblance in many respects to compli- 
cated traumatic infective fever. In both there are chills, fever, and sweating, 
with progressive emaciation and loss of strength. A careful analysis of the 
phenomena belonging to the two diseases reveals several points which may 
serve to establish the distinction. 
In complicated traumatic infective fever the chill is sudden and often very 
severe, the temperature very high, the fever intense, and the sweating pro- 
fuse; in hectic fever the chill, when present, is slight, the temperature only 
slightly elevated, the fever moderate and more of a continuous type, and 
the sweating by no means profuse. 
Hectic fever, moreover, is the product of a long-continued suppuration, and 
does not so rapidly exhaust the strength as the traumatic infective disease. 
Hectic fever has no tendency to produce secondary deposits in internal organs, 
though in subjects in whom there previously existed a strong constitutional 
proclivity to pulmonary disease suppuration may be developed in the lungs 
and even in other organs. This, however, is not due to the transposition of 
anything generated in a wound, but to inflammatory changes incident to 
constitutional weakness. 
Pneumonia, primary or idiopathic, which is sometimes developed in the 
progress of a surgical case, and which, commencing with a chill, followed by 
fever, cough, and hurried respiration, resembles in these features that pro- 
duced by infection, may nevertheless be referred to its proper source. This 
is done by considering that the announcing chill does not, as a rule, recur, 
and that the physical signs belonging to idiopathic pneumonia (such as dull- 
ness on percussion, the crepitating and subcrepitant rales, with bronchial 
respiration) are much more pronounced than in the infective pneumonia. 
Intermittent fever.-Persons who have been exposed in miasmatic districts TRAUMATIC FEVER. 
395 
often carry about with them the seeds of an intermittent, which may remain 
dormant for a long time, but are frequently called into activity by the shock 
attending a surgical operation. As a paroxysm of this fever consists in a 
chill followed by fever and sweating, and as these paroxysms are repeated, 
the resemblance to traumatic infective fever is very striking. There are, 
however, these points of difference. In intermittent fever the chill is gener- 
ally of longer duration, and the temperature is rarely so high. The com- 
pleteness, also, of the intermission, and the tendency to recur with great 
regularity as to time, will serve to distinguish it from complicated traumatic 
infective fever. 
Rheumatism, especially that form which involves the articulations, has been 
confounded with complicated traumatic infective fever. Except as a result of 
infection, swellings of the joints do not commonly follow operations. 
In rheumatic arthritis the articular effusion is usually serous and synovial, 
while from infection it is purulent. The signs on palpation will, conse- 
quently, be somewhat different. If the distinction cannot be appreciated by 
tact, the quality of the articular contents may be determined by the use of 
the aspirating needle. 
There are two features belonging to complicated traumatic infective fever 
which will serve to distinguish it not only from ordinary intermittents, but 
also from all the other affections with which it has been compared. These 
are the height as well as the ever-shifting degree of temperature present, and 
the rapidity with which it destroys the strength of its victims. 
Prognosis.-Recovery from complicated traumatic infective fever must be 
a matter of exceedingly rare occurrence. I can recall only a single case of 
the kind: so pronounced were all the symptoms of the disease that it is im- 
possible for me to believe that an error of diagnosis had been committed. 
An analysis of 29,434 surgical cases admitted into Guy's Hospital, London, 
during ten years, shows a mortality of 1749; and of this number 203 were 
from pyaemia, or 1 in 9 cases.* 
When recovery does take place, it will be in that form of the disease in 
which secondary deposits in the internal organs are not present. 
Treatment.-Hopeless though the disease appears to be when once estab- 
lished in the system, it is in the power.of the surgeon to do much by the use of 
the proper prophylactic measures to prevent its occurrence; and foremost 
among these is ventilation. Previous to the introduction of forced ventila- 
tion, by means of the fan, into the Pennsylvania Hospital, traumatic infection 
was very common in the surgical wards of that institution. Since the adop- 
tion of this plan, now five years, not a single case has occurred. So very 
remarkable has been the change in this respect that it gives great importance 
to atmospheric dust, or to the septic matter which it carries, as a source of 
blood-poisoning. Not only, however, is it necessary to have a constant re- 
newal of fresh air in a room or a ward devoted to the reception of surgical 
patients, but the utmost cleanliness must be enforced in regard to the instru- 
ments, the dressings, and the personnel of both physician and nurses. Every- 
thing employed about a wound should be thoroughly disinfected by the use 
of some preparation of carbolic acid or of permanganate of potash. 
The beds and bed-clothing should be frequently changed, aired, and exposed 
to a full sunlight, and the dejections of the sick should be promptly disin- 
fected and removed. 
In hospitals, as well as in private houses, the drainage must be rigidly 
examined, and if any defects exist they should be immediately remedied. 
Many of the " modern conveniences" which have been introduced into private 
dwellings, such as permanent washstands and water-closets, in view of the 
fact that no perfect trap has yet been devised to exclude sewer gas, are well 
calculated to contaminate the air of sleeping-apartments, and, I doubt not, 
are fruitful sources of erysipelas, diphtheria, and typhoid fever, and render 
such apartments quite unsafe for surgical patients. 
Bryant's Surgery, p. 40. 396 
TRAUMATIC FEVER. 
Too much care cannot be observed in the dressing of wounds. No clots 
should be allowed to remain. These undergo dangerous putrefactive changes, 
the products of which, entering the vessels, may cause serious poisoning. 
Of still greater importance is the matter of drainage, by which the results 
of tissue-metamorphosis and other accumulations are conducted away from 
the wound. 
Various internal remedies have been commended as possessing preventive 
properties, such as the hyposulphites, carbolic acid, permanganate of potash, 
chlorine water, alcohol, etc.; but their value as prophylactics has never been 
established to the satisfaction of the profession. 
When the disease has been once established in the system, drugs possess 
little, if any, value as curative agents. They may serve to retard the fatal 
event, but never to prevent it. Quinine or cinchonidia, given in doses of ten 
to twenty grains daily, will modify the suppurative chills, reduce the tempera- 
ture, and sustain somewhat the strength of the patient. The enormous doses 
of this drug given by Socin possess no special advantage in controlling the 
disease. Preparations of iron will also prove useful; and of these none are 
superior to the tincture of the sesquichloride, unless in cases wherein diar- 
rhoea is excessive, when the liquoi- ferri pornitratis may be advantageously 
substituted. 
Opium can also be given with good effect in cases of restlessness and sleep- 
lessness, or of pain or looseness of the bowTels. 
If to these remedies be added a moderate amount of alcoholic stimulants, 
and the free use of milk and animal broths, we have embraced that plan of 
treatment which, in my experience, seems to contribute most to the comfort 
of the patient. 
Various other remedies have been recommended,-as aconite by Textor, 
ergotin by Labat, veratria, and other medicinal articles; but experience has 
proven them to be inert as curative agents. CHAPTER XIX. 
furunculus, phlegmon, or boil. 
Furunculus, from the Latin word furo, to " rage," is a circumscribed in- 
flammation of the skin and cellular tissue, terminating in suppuration and 
the formation of a small central slough called the "core." It is an exceedingly 
common affection, and more generally met with in the young than in the 
adult and those advanced in life. 
Males and females are alike subject to furuncular inflammation. Boils may 
occur singly or in numbers; and, while no part of the body is exempt, there 
are localities where they most frequently appear, as the face, back of the 
neck, posterior part of the trunk, nates, shoulder, axilla, perineum, and 
thighs. 
There are two varieties of furuncle,-the complete and the incomplete or 
" blood boil," in popular phrase. In the latter the inflammation is less acute, 
and does not tend to suppuration. 
Boils are met with in two very diverse and opposite conditions of the 
system, namely, in the strong and plethoric, and in the feeble or those who 
suffer from a disordered state of the digestion. Not unfrequently they ap- 
pear during convalescence from a low form of fever. Exposure to a vitiated 
atmosphere is no uncommon predisposing cause, and hence the occurrence 
of such inflammation in the persons of hospital internes and in medical 
students much engaged in the duties of the dissecting-room. 
Children during dentition not unfrequently suffer from furuncle, as do young 
females subject to disturbances of the menstrual function. The irritation 
produced by a blister, or by the protracted use of poultices, especially when 
the latter have been allowed to become sour, is frequently followed by one or 
more imperfect or " blood boils." 
They are often associated with a diseased state of the kidneys, or with 
saccharine urine,-facts which should always suggest the necessity, in obsti- 
nate cases, or in multiple boils, of instituting a careful inquiry into the con- 
dition of the internal organs. Many persons during a temporary sojourn at 
the seaside are afflicted with furuncle, particularly those who indulge in surf- 
bathing. The intense heat of summer also has no small influence in causing 
their appearance. 
Not unfrequently the inflammation of furuncle originates around a hair or 
a sebaceous follicle, excited in the latter perhaps by some obstruction in the 
excretory duct of the gland. This is particularly true in those cases of the 
disease which appear in obese persons who are gross feeders. 
There may also be a furuncular diathesis, which will explain those cases in 
which persons suffer from frequent attacks of boils, and, more rarely, those 
in which large numbers appear simultaneously over different parts of the 
body. I once had under my care a gentleman who was greatly addicted to 
the pleasures of the table, whose entire body, save the palms of the hands 
and the soles of the feet (parts generally exempt), was covered with boils, 
from the effects of which he finally sank and died. Boils vary in size from 
that of a grain of shot to that of a pigeon's egg. 
Symptoms.-The formation of a furuncle is announced by the appearance of 
a fiery-red, painful pimple, which gradually increases into a hard, conical mass, 
the surface of which gradually becomes purple or violet colored. The pain 
at first is of a burning and smarting nature, but afterwards becomes throb- 
397 398 
FURUNCULVS, PHLEGMON, OR BOIL. 
bing. The glands in nearest relation to the boil are tender and swollen, and 
the muscles underneath the inflamed point stiff and sore. Every movement 
of the part provokes more or less pain, compelling the patient to maintain a 
fixed and mechanical attitude. Finally, a small vesicle rises on the summit 
of the conical mass, the induration begins to soften, and fluctuation can be 
distinguished,-signs betokening the existence of suppuration. 
Usually it requires from six to eight days for the furuncle to mature. It 
is only where the boil is quite large, or where a number of boils are simulta- 
neously present, that the general system sympathizes with the local disorder. 
Under such circumstances the patient may experience chilly sensations, even 
a rigor, followed by the loss of appetite, a coated tongue, headache, and some 
febrile excitement. 
The anatomical appearances presented by a furuncle in its incipiency 
cannot be exactly determined, as the opportunity for examination does not 
occur; but, from the regions selected by the disease, those in which the 
sebaceous glands most abound, and from the pain and the very limited and 
angry point of redness which characterize its early stage, the inflammation 
would appear to have its origin in the vascular net-work belonging to a 
sebaceous gland. When the swelling is laid open, we find a mass of dead 
connective tissue, interpenetrated by consistent yellow pus, or by pus and 
blood. It is this necrosed cellular tissue which constitutes the core of the 
boil, and which has perished by the intensity of the inflammatory transuda- 
tion. Occasionally the entire contents appear to be little else than blood, in 
which case the disease is called a 11 blood boil." The indurated circumference 
consists of a plastic infiltration of the surrounding areolar tissue, with in- 
creased vascularization, which, as in acute abscess, appears to be reared as 
a wall of limitation against the intrusion of the inflamed products, into the 
adjacent tissue. 
Treatment.-In the very commencement of the inflammation it is possible 
to cause the furuncle to abort. For this purpose a little blistering collodion, 
the strong mercurial ointment, tincture of iodine, ice, bichloride of mercury, 
and several other agents have been applied over the affected part. The most 
promising agent for this purpose, however, is a mixture of carbolic acid and 
glycerin, consisting of equal parts. A single drop worked into the summit of 
the boil with an ordinary quill toothpick will often effect its resolution. I 
doubt, however, if anything is gained by the abortive plan, even when suc- 
cessfid. The popular notion in regard to all such affections, that they are 
outlets for certain peccant matters or humors, and therefore possess, accord- 
ing to the vulgar opinion, some value, though it need not be expressed in 
money, is not without plausibility; and I therefore prefer to accelerate the 
suppuration by hot poultices of flaxseed-meal or by compresses of hot water, 
and, as soon as the swelling is sufficiently soft, to lay it open with a delicate, 
sharp-pointed bistoury, discharge the pus, and squeeze out or pick out the 
core with a pair of forceps. After this is done, a warm wet compress or a 
pledget covered with lead cerate, and a bandage bringing the sides of the 
cavity together, will soon complete the cure. 
When boils appear in numbers or follow one another in rapid succession, 
indicating a furuncular diathesis, general remedies are employed to correct 
the evil. Arsenic, iodine, mercury, liquor potass®, yeast, and other articles 
have been commended as possessing peculiar efficiency in arresting the disease. 
But I know of no specific for such a state. The vice can be corrected only 
by treatment based on general principles. If the patient is a person of a 
full, plethoric habit, overfed and over-stimulated, a mercurial purgative, fol- 
lowed from time to time by a saline laxative, with the use of an alkali, such 
as the bicarbonate of potash, constitutes the most rational plan of treatment. 
In sickly, exhausted persons, with bad hygienic surroundings, an opposite 
course must be pursued. Iron, quinine, mineral acids, red wine, a nutritious 
diet, and fresh air are indispensable requisites. Medical students and hos- 
pital internes who suffer from boils should at once detach themselves from ANTHRAX, OR CARBUNCLE. 
399 
their accustomed duties and go into the country until their constitutional 
forces have been recovered. To linger longer in a vitiated atmosphere is to 
invite an attack of typhoid fever, or to endanger their lives by the risk of a 
poisoned wound. 
Anthrax, like furuncle, is the result of a cutaneo-cellulai* inflammation 
followed by suppuration and sloughing, the chief differences between the two 
being the intensity of the process, its greater tendency to spread, and the 
presence of multiple openings which exist in carbuncle. Indeed, anthrax 
may, without committing the least anatomical violence, be defined as a col- 
lection of boils, each opening on its surface and answering to one member of 
the group. 
Carbuncles differ in size, varying from one inch to six inches in diameter. 
In an old man who was under my care, in the surgical department of the Phil- 
adelphia Hospital, for anthrax, the anterior part of the chest was involved 
to an extent which would have been barely covered by a large dinner-plate, 
and yet, notwithstanding the great exhaustion, the patient struggled suc- 
cessfully through the disease. 
Carbuncles commonly select for their site those portions of the body on 
which integument is thick and dense: thus, they are met with on the back 
of the neck and the trunk, on the scalp, over the nates, occasionally on the 
thigh, and upon the chin, and less frequently on the side of the face near 
the nose. In the last two localities the presence of carbuncle is always 
attended with danger. 
Anthrax is seldom witnessed in persons before mature life, and generally 
appears after the age of fifty. 
Causes.-The causes of carbuncle are of a general rather than a local nature. 
The disease is never seen in persons enjoying sound health. Those who lead 
an indolent or sedentary life, and who indulge in the pleasures of the table, 
are peculiarly prone to suffer from its attacks. In such the digestive organs 
are overtaxed, and from habits of inactivity the products of tissue metamor- 
phosis are not eliminated as they should be by those important emunctories, 
the glands of the skin and the kidneys; consequently, by their retention or 
new chemical combinations, the blood is loaded with poisonous materials, 
which, in the process of discharge through the emunctories of the skin, 
kindle local inflammation. Those, again, whose constitutions have been 
damaged by intemperance, deprivation, and vicious indulgences are proper 
subjects for carbuncle. Diabetes mellitus and albuminuria are also condi- 
tions strongly predisposing to carbuncle. The season of the year appears 
to have some influence in producing carbuncular inflammation, as most cases 
occur during winter and spring months, possibly on account of the effects 
of cold, sudden changes of temperature, and the in-door life which many per- 
sons lead,-causes which tend to disturb the functions of the skin. Males 
are more frequently attacked than females. 
Symptoms.-The earliest sign of carbuncle is the appearance of a small, 
red, pointed pimple, accompanied by an itching, burning, or smarting pain, 
the peculiar severity of which would seem to be entirely disproportioned to 
the size of the vesicle. The base of the pimple enlarges in its circumference 
equally on all sides, is hard, brawny, and at first but slightly raised above the 
level of the surrounding skin, which presents a dusky-red appearance. As the 
swelling increases, it assumes more of a conical or mound-like shape, the color 
becoming more purple or livid, and the pain having a throbbing character. 
In addition to these appearances, there is experienced a feeling of extreme 
tension. All the muscles in the neighborhood become sore and rigid, and the 
lymphatic glands in the vicinity tender and enlarged. It is usually at this 
stage that small vesicles begin to form, each one becoming a little slough, and, 
after being broken, leaving a number of openings over the surface of the 
swelling, giving to the carbuncle a cribriform appearance, and exposing at 
Anthrax, or Carbuncle. 400 
ANTHRAX, OR CARBUNCLE. 
the bottom of each opening a gray slough of cellular tissue. These openings 
enlarge irregularly. Through them discharges a thin, irritating, ichorous 
fluid, derived from the decomposing connective tissue below. 
In bad cases, constitutional symptoms of an asthenic type appear very 
early in the course of the inflammation, not uncommonly ushered in by a 
chill, followed by fever. The tongue becomes dry and brown; the taste is 
perverted, and the appetite lost; the complexion becomes sallow; the urine is 
diminished, and along with a frequent feeble pulse there is a rapid loss of 
strength. There is a form of carbuncle which is occasionally seen on the lips 
or faces of young persons, exhibiting a remarkable tendency to spread. It 
is attended with much swelling and alteration of the features, rapidly pre- 
cipitating the system into a low, typhoid condition, and, unfortunately, little 
amenable to treatment. Though the inflammation is carbunculous, it cer- 
tainly depends on causes differing from those producing ordinary anthrax, 
as it exhibits no tendency to limitation, and but little to suppuration or 
ulceration. The fatal termination seems to be due to extension of the in- 
flammation along the veins or lymphatics to the brain, or to pyremic changes 
in the blood. 
Diagnosis.-Carbuncle can be scarcely confounded with any other affec- 
tion. Its extreme diffused hardness and violent burning and itching pain, its 
multiple openings, its slow progress, and the accompanying constitutional 
disturbance, are sufficiently distinctive to prevent its being confounded with 
furuncle. 
Prognosis.-Unless the carbuncle is unusually extensive or is multiple, and 
the patient aged and exhausted, recovery generally takes place. When the 
disease begins on the scalp or the face, or extends from the neck to the head, 
the patient being old and infirm, life is in great jeopardy. If complicated with 
diseased kidneys or with saccharine urine, the progress of the disease will 
be towards a fatal termination. 
Anatomical structure.-Upon making a section of a carbuncle, especially 
near its circumference, the density of its substance, in consequence of the 
compact infiltration, is so great that the sensation communicated through the 
knife is not unlike that produced by cutting into a fibroid tumor. Each open- 
ing on the surface of the swelling marks the position of a former slough of 
the skin. In the interior there lies a slough of connective tissue, resembling 
in appearance and color a mass of wet felt, and bathed in a thick, purulent 
fluid. At the circumference of the swelling the same plastic infiltration of 
areolar tissue and the same vascularization as in furuncle exist. 
Treatment.-The treatment of carbuncle is very simple. The indications 
are to arrest the extension of the inflammation, to expose and remove the 
slough as quickly as possible, and to sustain the powers of life while this 
process and the subsequent closure of the ulcer are being accomplished. To 
arrest the extension of the carbunculous inflammation and to expose and re- 
move the disorganized connective tissue, four different plans have been pur- 
sued. The first plan, with a few exceptions, is the one to which I am partial. 
It is carried out most satisfactorily by preparing a flaxseed-meal poultice, 
sprinkling over its centre a little coarsely-powdered crude soda, and covering 
it with a piece of tarlatan upon which has been spread a layer of compound 
resin ointment. This is to be applied to the carbuncle as warm as can be 
borne, and, in order that the heat and moisture may be retained, it should be 
covered with a piece of oiled silk. Some add a little yeast to the poultice; 
but I have seen no special advantage following its use. 
This dressing requires to be renewed every six hours. The effect of the 
heat and moisture is to hasten suppuration and to relieve tension and pain, 
by softening the tissues and thereby diminishing the pressure on the nerves 
of the inflamed part. The alkali, by its caustic properties, facilitates the 
formation of little sloughs of skin which naturally occur. As soon as these 
sloughs drop out from the surface of the carbuncle, the soda may be with- 
drawn, and the poultice, with its stimulating ointment, continued. The ANTHRAX, OR CARBUNCLE. 
401 
openings rapidly enlarge and run into one another, until, in a short time, a 
kind of crater is formed, which exposes the dead cellular tissue below. 
As the sloughs loosen they are to be picked away with the forceps. In 
doing this it will sometimes be necessary to sever their surrounding connec- 
tions with the scissors, always observing to keep within the limits of the dead 
tissue, so as to avoid hemorrhage. 
After detaching such portions as admit of being readily removed, the sur- 
face of the ulcer is to be washed free from all the discharges by injecting, 
through the remaining portions of the slough, a solution of permanganate 
of potash, after which the poultice with the resin ointment is again to be 
applied. 
This procedure should be repeated morning and evening until all the dead 
tissue is removed, when the ulcer will rapidly be filled up by granulations. 
During this process and that of cicatrization the resin cerate is all the 
dressing that is necessary. 
When a large carbuncle has been once cleared of its necrosed areolai' tissue 
the remaining opening presents an appearance of great depth. This, how- 
ever, is only in appearance, being due to marginal thickening, which is 
slow to disappear. The cavity of a carbuncle very seldom transcends the 
limits of the deep fascia or the sheaths of the muscles. It is also worthy 
of observation that, notwithstanding the great loss of substance occurring 
in carbuncle, deformity from cicatricial contraction is rarely met with. 
This is very strikingly exemplified after carbuncles on the back of the 
neck. 
Vesication.-When the carbunculous inflammation exhibits a tendency to 
spread, the tumor rising only slightly above the surface, the extension of 
the disease may be very decidedly arrested by the application of a blister 
large enough to extend half an inch beyond the limits of induration. The 
free discharge of serum appears to mod- 
erate the intensity of the inflammation 
and the profuse infiltration, both of which 
are hostile to that circumferential wall of 
lymph which arrests the progress of the 
disease. When the carbuncle has been 
brought to a halt, the treatment by poul- 
tices becomes proper. 
Incision.-At one time, following in the 
wake of surgical practice, I was in the 
habit of making the traditional crucial in- 
cisions in all cages of carbuncle. (Fig. 
1235.) One day I was called to see two 
patients very much alike in constitution 
and habits of living, and each suffering 
from a large carbuncle. In one case I 
incised freely, as a preliminary part of 
the treatment; in the other I employed 
heat and moisture. Both patients re- 
covered at the same time. Since then 
eighteen years have passed, and I have 
rarely incised a carbuncle, though very 
many cases of the disease have been under 
my care. The operation, as a rule, neither 
hastens the cure nor lessens the suffering. 
The only form of carbuncle in which 
the use of the knife is demanded is that 
on the face or lip, which should be cut 
the moment the inflammation manifests a 
tendency to diffusion. When too profuse a hemorrhage fallows the incision 
of a carbuncle, the wounds should be filled with rolls of lint soaked in hot 
Fig. 1235. 
Crucial incision of carbuncle. 
vol. ii.-26 402 
ERYSIPELAS. 
alum-water, and a compress and bandage applied for a few hours. When 
the painful sense of tension and throbbing cannot be relieved by moderate 
doses of anodynes, I would not interdict incision. 
Cauterization is applied in two ways: first, by caustic potassa applied to 
the surface of the carbuncle, as a substitute for cutting; and, secondly, by the 
same agent being rubbed into the incision,-a twofold barbarism. 
Besides the methods already described there has been advocated subcuta- 
neous incision by Mr. French, in which a tenotome is introduced into the 
carbuncle at three or four points, and its cellular tissue divided in different 
directions before withdrawing the instrument. Pressure has also been favor- 
ably spoken of by Dr. O'Ferrall; but, after no small experience in this kind 
of surgery, I can say that these plans of treatment possess no special merit 
whatever. 
Constitutional treatment.-The constitutional treatment of carbuncle should 
not be overlooked. The system, throughout the entire progress of the 
disease, requires the most generous support. The state of the intestinal 
secretions should be inquired into; and if it requires correction, a gentle 
cathartic, preceded by a little calomel or blue mass, may be given, after 
which the muriated tincture of iron and quinine constitute the most valuable 
tonics. Opium in some form, to relieve pain and restlessness, is indispensable. 
Milk, animal broths, and eggs must supplement any deficiency in the amount 
of solid food which the patient is able to take; milk-punch and wine may 
be freely given. 
A person who has successfully passed through a long carbuncular attack 
will generally be left in a weak and depressed state for some time. A change 
to the seaside or the mountains will aid in restoring the wonted constitutional 
vigor and health, provided the season of the year is favorable. 
Erysipelas. 
Erysipelas is one of those acute inflammatory febrile affections which in 
many instances complicate surgical diseases. Its presence is always a source 
of great anxiety to the surgeon. It may be either idiopathic or traumatic, and 
may appear in either a sporadic or an epidemic form. It is both infectious 
and contagious. It is the traumatic form of the disease which possesses the 
greatest interest to the surgeon. The varieties of erysipelas may be divided 
anatomically according to the particular tissue-plane involved. Thus, we 
have the cutaneous, the cutaneo-areolar, and the areolar. The inflammation, 
however, is not limited to these structures. It may extend below the deep 
fascia, implicating the intermuscular connective tissue, the muscles, the 
periosteum, and the bones. The membranes lining both open and closed 
cavities, as the mucous and serous, the blood-vessels, and the lymphatics, are 
also the subjects of this affection. Any portion of the body may be invaded 
by erysipelas. The face and the scalp suffer most in what is termed the idio- 
pathic form of the disease; in the traumatic variety the lower extremities 
are affected oftener than the upper. 
Causes.-The causes of erysipelas are predisposing and exciting. 
Predisposing Causes.-Among these may be mentioned intemperance, 
gluttony, obesity, diabetes, disease of the kidneys, exhaustion from loss of 
blood, disorders of the liver and of the digestive organs, and bad hygienic 
surroundings, such as overcrowding of wounded patients, imperfect ventila- 
tion, and defective drainage. 
The puerperal state.-The relation between erysipelas and puerperal perito- 
nitis has long been observed. The uterus at this period is particularly vul- 
nerable, and the most lamentable loss of life has occurred from accoucheurs 
attending at the same time cases of erysipelas and women in labor. At one 
time in Lancaster County, Pennsylvania, a fatal puerperal peritonitis pre- 
vailed, which carried off a large number of parturient women. This fatality 
occurred chiefly in the practice of a gentleman who had under his care cases ERYSIPELAS. 
403 
of erysipelas, and who was at first skeptical as to the communicability of the 
disease through personal contact. The epidemic ceased only when he with- 
drew for a time from obstetrical duties and supplied a substitute. No period 
of life is exempt from erysipelatous inflammation; but the largest number 
of cases are met with in persons over fifty years of age. Males and females 
are alike liable to the disease; but the former suffer more frequently, simply 
because their occupations expose them more to those accidents which play 
so important a part in originating the inflammation. 
Season of the year.-On this point there is some difference of opinion. In 
this country and in England the largest number of cases of erysipelas develop 
during the months of January and February. In Vienna the disease, during 
a decade, was most common in the spring and fall months; and in Berlin, 
during the winter and spring. 
Dampness.-Wet weather exercises no small determining influence in the 
production of erysipelas. Indeed, the presence of the disease during a cold 
or warm dry state of the atmosphere is by no means common. 
Hereditary influences must also be recognized among the conditions predis- 
posing to the disease. There are many instances of parents transmitting 
this tendency to their children. 
Other constitutional peculiarities are sometimes met with, such as when the 
disease appears periodically three or four times a year in the same person. 
Exciting Causes are wounds and contagion. Any wound, whether incised, 
lacerated, punctured, poisoned, or gunshot, may develop the disease. Those 
injuries in which the tissues are bruised or torn, or which were received under 
circumstances tending to confine the inflammatory products of the injury, 
are most favorable for inducing an attack of erysipelas. Hence the frequency 
of this inflammation after crushes of the limb or after punctured wounds. 
In such cases the immediate irritant is no doubt in the products of devitalized 
tissue, provoking an inflammation in the contiguous lymph-vessels. In the 
vast majority of cases of erysipelas, a wound, however trivial, is a necessary 
complement to the existence of the disease, which would rarely appear with- 
out it. 
There are peculiar states of the general system, or of the atmosphere, when 
the slightest scratch of the skin, even the bite of an insect, is followed by 
an erysipelatous attack. This personal liability is not always limited to the 
narrow compass of a hospital ward or a private dwelling, but may affect 
districts several miles in extent. It is during such periods that persons suf- 
fering from bone-disease attended with fistulous openings, or from unhealed 
wounds or chronic ulcers, often have attacks of erysipelas, commencing in 
their open sores; and at such times a prudent surgeon will decline all cutting 
operations other than those of absolute necessity. 
Infection.-The infectious nature of erysipelas is predicated on several con- 
siderations. Many persons suffer from the disease in consequence of receiv- 
ing a slight scratch while making an autopsy. Foul sponges, soiled dressings, 
even the hands and clothing of a careless nurse, are sufficient to communicate 
some peculiar materies morbi to a wound which is capable of developing this 
form of inflammation. Orth,* in a series of twenty experiments, succeeded 
in communicating erysipelas to the lower animals from man, by introducing 
beneath the skin the serum obtained from the flaps and the subcutaneous 
tissue of a part affected with the disease; and Doepp gives the history of 
nine children who were inoculated from a scab taken from a child in whom 
the vaccine lymph had produced an attack of erysipelas. They all had an 
attack of the disease. For five years not a case of erysipelas developed in 
the surgical wards of the Pennsylvania Hospital; but very recently, during 
the cleansing of the walls of these same wards, quite a number of cases 
suddenly made their appearance. 
Contagion.-Although the theory is questioned by some, there are very 
cogent reasons for believing that erysipelas is communicated by contagion, 
* Schmidt's Jahrbuch, xxx. p. 184. 404 
ERYSIPELAS. 
in some invisible miasm which is borne in the air adherent to organic dust. 
In what other way can we explain the simultaneous appearance of the dis- 
ease in the different wards of a hospital, or the fact of a number of persons 
in the same ward or room being attacked at the same time? Of this there 
are numerous examples. 
Volkmann* furnishes a curious history of an eruption of erysipelas which 
strongly corroborates the contagion theory. The disease commenced in a 
ward containing thirteen beds, arranged in two rows on opposite sides of the 
apartment, and passed from bed to bed, affecting all the patients on one side, 
then returned in the same regulai' manner on the opposite side, until twelve 
out of the thirteen patients were attacked. 
Cutaneous Variety.-This form of the disease is sometimes regarded as an 
erythema; but I do not admit the identity of the two inflammations. On 
the contrary, I regard them as entirely distinct. Erythema never tends 
to implicate the subcutaneous cellulai* tissue, is not communicable, does not 
vesicate, and never follows a wound,-peculiarities which pertain to erysip- 
elas. Neither does erysipelas recede and then reappear in the same place, as 
it is common for erythema to do. 
Symptoms.-Cutaneous erysipelas may appear without any noticeable con- 
stitutional disturbance, the first indication of the disease being the appearance 
of an intensely red or scarlet blush, with tension of the surface, situated, 
when it is of a traumatic origin, at the margin of, or contiguous to, the 
wound. The attendant pain is of a pungent or burning character. The 
redness, instead of being sharply defined, usually blends insensibly with 
the color of the healthy skin, and is sometimes exchanged for a dusky hue, 
When pressed upon with the finger, the vessels of the inflamed surface 
are temporarily emptied, leaving the part white, but only for a moment, as 
the blood instantaneously returns to the capillaries. There is very slight 
transudation, and consequently but little, if any, swelling. In two or three 
days the redness disappears and is followed by desquamation. Not unfre- 
quently, after leaving one part it will appear in another, constituting the 
erratic or wandering form of the affection, answering to the fourth species 
of Willan. 
In the more serious forms of this variety of erysipelas, the cuticle is raised 
into blebs or vesicles containing a semi-transparent serum, which soon becomes 
turbid. The inflammation, especially in the idiopathic variety of the disease, 
may rapidly extend over the contiguous portion of a limb or the trunk, or, if 
on the face, to the ears, the eyelids, and the scalp. The lymphatic glands 
become slightly enlarged. The eyelids are swollen, tense, and closed, and the 
face is so entirely disfigured and altered in its appearance by the swelling 
that it is often impossible to recognize a single natural feature of the coun- 
tenance; there is also very great tenderness. In two instances of cutaneous 
erysipelas, both following operations (the one after an excision of the mam- 
mary gland, the other after the removal of a sebaceous cyst of the scalp), 
the inflammation in the first case spread from the breast upward and down- 
ward, until the entire body was involved ; and in the last case, beginning 
on the head, it gradually descended and disappeared at the toes. 
When the erysipelas arises from a traumatic cause there is often noticed 
an alteration in the wound, the discharges from which entirely subside, or 
become bloody and serous instead of being purulent. 
The constitutional symptoms which usher in an attack of this nature are 
nausea, headache, rigors, alternating with flashes of heat, accompanied with 
a dry tongue, hot skin, frequent pulse, and a high temperature, reaching not 
unfrequently 103° to 105°. These signs may antedate the local manifesta- 
tions twenty-four oi' thirty hours, or they may appear coincidently with 
them. The tendency of the fevei' is generally towards a low or typhoid form; 
and when the inflammation spreads over the face and scalp it is usually at- 
* Ziemssen's Cyclopaedia, vol. ii. p. 435. ERYSIPELAS. 
405 
tended with more or less mental wandering. In the last-named condition the 
disease may pass beyond the limits of the skin and invade the mucous mem- 
branes of the eye, nose, mouth, and fauces, extending even to the pharynx, 
larynx, and trachea. On the third or fourth day both the fever and the 
inflammation have, ordinarily, culminated, and from this period onward there 
is a gradual and concurrent subsidence of both the general and the local 
phenomena; the redness fades and changes to a yellow color, the swelling 
subsides, and the parts become more tolerant of pressure. The vesicles and 
blebs burst, allowing their contents to desiccate into yellowish scales, and 
sometimes into brown crusts, or the serum may be absorbed. In either event 
there is a free desquamation of furfuraceous scales, leaving the skin corrugated 
and stiff for many days after the disease has passed away. 
If the scalp has been the seat of the affection, the hair falls; but, as the 
follicles are not destroyed, it is reproduced as abundantly as before the attack. 
Cellulo-Cutaneous or Phlegmonous Variety.-As the name implies, this in- 
flammation is not confined to the skin, but extends into the subcutaneous 
connective and adipose tissues. The attack is generally, as in the othei' 
variety, preceded by a rigor or chill, followed by a hot skin. These may be 
repeated several times before the local signs attract attention, and may be 
mistaken for the commencement of an ordinary intermittent. As compared 
with the cutaneous variety the swelling is greater, the induration harder and 
deeper, the color less red, having a dusky, dark, or mottled tint, according 
to the degree of embarrassment experienced by the venous circulation; the 
skin is glossy and shining, the pain more severe, perhaps throbbing, and the 
vesication or blebs, when present, somewhat larger. (Edema is also present. 
The inflammation exhibits a marked tendency to become diffuse by extend- 
ing through the connective tissue, and finally, unless arrested, terminates in 
suppuration, which, not being circumscribed by any wall of lymph and show- 
ing no disposition to point, is liable to cause sad havoc with the superficial 
fascia. The formation of pus in the subcutaneous tissue is announced by the 
peculiar soft, boggy feel of the parts, and not unfrequently by a recurrence 
of rigors. In neglected cases the inflammation may pass beyond the boundary 
of the deep fascia, and the resulting suppuration occasion extensive disorgani- 
zation of the muscles and other components of the part. 
When the inflammatory transudation is very sudden and abundant, the 
subcutaneous cellular tissue may perish from the strangulation of its vessels 
and be discharged in the form of gray sloughs. 
The constitutional symptoms accord with the local condition, the fever as- 
sumes more and more a typhoid character, there is much nervous irritability, 
with loss of strength; and, when the scalp is affected, delirium is usually 
present. If the disease tends to a fatal termination, the tongue, at first 
covered with a white, cheesy-looking coat, becomes dry and covered with 
patches or streaks of a yellow and finally a brown or black crust, between 
which the surface of the organ is red, dry, and glazed. The thirst increases; 
the appetite is gone; and the patient suffers from nausea and occasional 
vomiting. If the disease tends to a fatal termination, the sclerotica, con- 
junctiva, and face assume an icterode hue; bile appears in the urine; sordes 
collect about the gums; diarrhoea sets in; the pulse becomes frequent and 
feeble, and the patient sinks into a state of coma, which in a short time ends 
in death. 
Subcutaneous Erysipelas, sometimes called diffuse cellulitis, may exist 
without any inflammation or redness of the skin, and is, consequently, liable 
to progress for some time undetected. It does not always commence at a 
wound, but may first appear at some distance from the latter. It may arise 
from a compound fracture, or from a poisoned wound, as that resulting from 
the bite of a venomous snake or from a puncture received while making an 
examination of the dead body. It may be idiopathic. In one instance I 
witnessed the sloughing away of the entire subcutaneous cellulai' tissue of the 406 
ERYSIPELAS. 
lower extremity from the ankle to the crest of the ilium. The patient was 
a man seventy years of age, and could only refer the disease to having taken 
cold while sleeping in a damp room. In aggravated cases of both cutaneous 
and facial erysipelas there is a tendency to suppurative inflammation in parts 
more or less remote from the original seat of the disease: thus, an opposite limb 
from the one affected, or one of the joints of the same limb, may be attacked. 
In like manner the mucous membrane of the fauces, pharynx, and larynx 
may suffer, and so also the serous membranes, as the pleura, the peritoneum, 
and the arachnoid. With regard to the last, the arachnitis which frequently 
follows erysipelas of the hairy scalp is doubtless merely an extension of the 
inflammation by blood-vessel continuity, as the vascular unity of the extra- 
and intra-cranial parts is well known. The same anatomical fact will explain 
the appearance of the disease in the fauces,-a peculiarly dangerous compli- 
cation. Erysipelas of the fauces and pharynx is announced by the intensely 
red, glossy, swollen, and oedematous state of the fauces, pharynx, and tonsils, 
the latter, together with the half arches, becoming covered with patches of 
lymph, and imparting, through the vitiated secretions, a highly offensive 
odor, the inhalation of which is not unattended with danger to physicians 
and attendants. There is also more or less difficulty in swallowing. In some 
instances facial erysipelas is secondary to that of the throat. 
Erysipelas of the Larynx.-When the inflammation travels beyond the 
boundaries of the fauces, the larynx is liable to suffer. The inflammatory 
transudation of the loose cellular tissue about the base of the epiglottis and 
the glottis produces an oedematous state of these parts, which is followed 
by difficult respiration and loss of voice, in some respects simulating croup. 
The extension of the disease to the lungs, causing pneumonia, though not 
common, does sometimes occur. 
Synovial and Serous Membranes.-Where a joint, or the pleura, or the 
peritoneum is attacked, it is, in many cases at least, difficult to trace the re- 
lation between these complications and the primary erysipelas, except through 
the infection of the blood, in which case they stand related to the original 
disease in the same manner as the secondary accidents of complicated surgical 
fever do to a wound. I am aware that all connection between pyaemia and 
erysipelas is denied by some, and that facts are adduced in corroboration of 
this view. For example, it is stated that at the St. Andre Hospital, Bordeaux, 
in 1844, erysipelas was so prevalent that a blister or a leech could not be ap- 
plied without the application being followed by an attack of the disease, and 
yet there were no cases of pysemia. Again, at the military hospital at Traute- 
nau, in 1866, there were many cases of pyaemia, but no erysipelas; and in 1870, 
at the Berlin Military Hospital, Retzmann observed both erysipelas and 
pyaemia, but not at the same time. With no disposition to challenge the 
accuracy of these statements, I have the most incontrovertible reason- 
namely, the testimony of the post-mortem knife-for knowing that patients 
suffering from erysipelas do sometimes die from pysemic infection. 
Duration of the disease.-The duration of erysipelas varies very much in dif- 
ferent cases. When seated on the head and face it is most obstinate, contin- 
uing, as a rule, from seven to fourteen days. On the trunk the disease rarely 
subsides in less than ten days; and when located on the upper or lower ex- 
tremities it remains from eight to ten days. In exceptional cases, erysipelas 
may continue for six or eight weeks. Occasionally we meet with instances 
of relapsing erysipelas, in which, just as convalescence has apparently been 
well established, another eruption of the disease appears, and this may be 
repeated several successive times: under such circumstances the affection 
may be prolonged far beyond the usual period. 
Explanation of the phenomena.-There are several peculiarities connected 
with this disease which will attract attention. Among these I will mention 
the manner in which the inflammation extends, in one place sending out long, 
tongue-shaped patches of redness, in another assuming a crescent form, and 
in another making a considerable detour to avoid a particular point, appearing ERYSIPELAS. 
407 
again on the opposite side. This behavior of the disease has an anatomical 
explanation. The interlacing of the connective-tissue bundles is arranged in 
such a manner that the interspaces, usually occupied by masses of fat, have 
an elongated form. It is on the circumference of these spaces that blood- 
vessels are distributed. The subcutaneous connective tissue is connected to 
the skin above, and to the deep fascia below, by numerous fibres, many of 
which have a perpendicular direction. The tension which results from the 
inflammatory infiltration compresses the vessels at some points more than 
at others. Into those whose channels are freest the blood is determined, 
and in the same direction the infiltration will spread, so that the redness 
and swelling move together. There are portions of the body in which the 
skin is held closely to the deep fascia by threads of connective tissue,- 
as over Poupart's ligament, at the linea alba, and below the nates. The 
same arrangement exists wherever there are furrows or wrinkles on the 
surface of the skin. These are localities in which the fascia refuses to 
yield, or yields very slowly, to transudations, and where, in consequence, 
the vessels must be subjected to strong pressure. Accordingly, we find 
that the redness of erysipelas will march directly up against one of these 
barriers, and either pass round at its extremities or linger a considerable time 
before surmounting the obstacle, after which its progress again becomes rapid. 
It will be found that on those portions of the body where the tension of the 
superficial fascia is uniform-as over the abdomen, the back, and the hairy 
scalp-erysipelatous inflammation will move in a regulai' and unbroken wave. 
The enlargement of the glands which so often accompanies severe attacks 
of erysipelas is an infective result, and due to an irritation caused by the 
presence of morbid products entering the nearest lymphatic vessels. The 
swelling and induration of the inflamed part are dependent on the infiltra- 
tion of serum and lymph into the subcutaneous tissue. The pressure of the 
transudation on the skin nerves gives rise to the increased sensibility and 
pain experienced. The shining, glossy appearance of the skin is the result 
of stretching and desquamation, and the vesicles or blebs which appear on 
the cutaneous surface are elevations of the cuticle filled with serum. These 
vesicles frequently contain great numbers of bacteria. The boggy feel com- 
municated to the touch in a case of deep or subcutaneous erysipelas is due 
to the formation of an uncircumscribed collection of pus lying in the midst of 
a mass of dead connective tissue, and the diminished sensibility which accom- 
panies this condition is to be referred to the disorganization of the nerves 
which run through this tissue. 
Post-mortem appearances.-These may be divided into three, found in the 
skin, in the subcutaneous tissue, and in the internal organs. The skin presents 
the appearance of an acute dermitis. The corium and the underlying cellular 
tissue are swollen and are interpenetrated by granular leucocytes and by 
serum. The blood-vessels are distended and crowded with corpuscles, and, 
together with the superficial lymphatics, which are also filled with granular 
cells, are surrounded with these cell-forms, which crowd the tissue, and whose 
presence is due to proliferation and emigration. These appearances of the skin, 
according to the observations of Volkmann and others, are confined to the first 
three or four days of the disease; after which they disappear, leaving the 
skin very much as before the attack. The subcutaneous tissue will be found 
infiltrated with serum, lymph, and pus; the lymph presenting a light, creamy- 
like appearance, and the pus having a yellowish-green or reddish color. The 
connective tissue is changed into a gray or ash-colored slough, somewhat re- 
sembling wet tow. When the inflammation has passed beneath the deep 
fascia the muscles are seen separated from one another by the fibrinous and 
purulent products; and in some instances even the bones are laid bare, from 
the detachment of the periosteum. Hueter found in the fluids of the inflamed 
tissues numerous bacteria of different forms. 
The signs of internal inflammation have been generally noted in fatal cases 
of the disease. Within the cranium the arachnoid is found with patches of 408 
ERYSIPELAS. 
opacity; the vascularity of the pia mater is materially increased, and its 
connective tissue infiltrated by a sero-purulent fluid; and in the ventricles of 
the brain is a similar product. In the chest are seen analogous inflammatory 
results, the pleura being thickened and made adherent in some places by 
unhealthy lymph, its cavity containing a dirty serum and pus, intermingled 
with flakes of cheesy matter. In the abdomen, both the visceral and the 
parietal peritoneum exhibit like changes with those of the pleura. The 
spleen is swollen, and in the kidneys the evidences of a diffused nephritis 
are present. 
Diagnosis.-The recognition of erysipelas is not difficult. The intensely 
red and shining appearance of the skin, its hot, oedematous, sensitive, and 
swollen condition, and the elevated temperature and pronounced consti- 
tutional disturbance, are quite significant of the nature of the disease. 
The only affections with which erysipelas is liable to be confounded are ery- 
thema, phlebitis, angioleucitis, diphtheria, and quinsy. Erythema, however, 
is transitory, is not accompanied with pain, swelling, or vesication of the 
skin, is attended with very little, if any, alteration in the temperature, and 
is not followed by desquamation. In phlebitis, the redness, hardness, and 
tenderness are confined to the course of the affected vein, instead of being 
diffused, as in erysipelas. In inflammation of the lymphatics, the redness 
and morbid sensibility are also limited, being linear and confined to the 
course of those vessels. The greatest difficulty will be encountered in distin- 
guishing erysipelas from diphtheria. In both there are redness, swelling, and 
exudation of the mucous membrane of the throat, and in both marked con- 
stitutional symptoms of an adynamic type. The distinction may be estab- 
lished by the nature of the prevailing epidemic, and by the great debility 
and the absence of paralysis of the palate in erysipelas. The nasal mucous 
membrane is also generally less involved in this disease. In quinsy, the 
swelling of the throat is greater and the constitutional symptoms are less 
severe than in erysipelas. The redness which accompanies nettle-rash and 
the poisonous action on the skin of certain plants, as the Rhus toxicodendron, 
may be mistaken for erysipelas; but the severe pricking pain of the first and 
the intense itching of the last, with the absence of chills and fever, would be 
sufficient to determine the true nature of the affection. 
Prognosis.-Although erysipelas is always a source of anxiety to the sur- 
geon, the fatality of the disease is not very great. The circumstances which 
influence the death-rate are various, such as the habits and age of the patient, 
whether temperate or the reverse, young or in advanced life (being more un- 
favorable in children and old persons than in those of middle age) ; the char- 
acter of the disease, the subcutaneous being more serious than the cutaneous 
form; the situation of the inflammation, erysipelas of the head, fauces, and 
larynx being always attended with danger; to which may be added the 
nature of the epidemic when generally prevailing, in some instances being 
very virulent and in others mild; and, lastly, locality,-the disease being 
usually worse in hospitals (especially when many wounded persons are 
crowded together) than in private life. If after five or six days the pulse 
continues to increase in frequency and the temperature to rise, there is ground 
for grave apprehension. 
The estimated fatality, as computed by different writers, varies from 3 to 50 
per cent. Taking all cases together, both medical and surgical, the mortality 
may be set down at about 12 per cent.,-an estimate based on an analysis of 
700 cases. An examination of 212 cases of erysipelas occurring at St. Bar- 
tholomew's Hospital, London, during a period of eight years, and which have 
been arranged for me in tabular form by Dr. Baum, of this city, exhibits some 
points of interest in connection with this subject. ERYSIPELAS. 
409 
Cases of Erysipelas which developed in Surgical Wards and also after Opera- 
tions at St. Bartholomew's Hospital. 
Deaths. Per Cent. 
Male- maTe. Total- /ent. Year' 
Fe- 
Male. maje Male. Female. 
Developed in wards 13 11 1 ... 5.88 33 3.03 1869 
After operations 4 5 
Developed in wards 12 6 4 2 23.52 21.42 31 22.58 1870 
After operations 5 8 ... 1 
Developed in wards 4 1 2 1 40.00 100.00 6 50.00 1871 
After operations 1 
Developed in wards 14 7 2 4 14.28 50.00 22 27.27 1872 
After operations 1 
Developed in wards 5 4 20.00 17 11.76 1873 
After operations 2 6 ... 2 
Developed in wards 18 5 2 ... 10.71 18.75 44 13.63 1874 
After operations 10 11 1 3 
Developed in wards 13 13 3 1 20.00 5.88 32 12.50 1875 
After operations 2 4 
Developed in wards 11 4 3 ... 23.52 27 14.81 1876 
After operations 6 6 1 
120 92 19 14 15.83 15.21 212 15.21 
Of the 212 cases, 120 were in males and 92 in females; 33 proved fatal,- 
19 of the deaths being males and 14 females; 72 cases of the disease followed 
operations done in the hospitals, and of this number only 8 died. In the 
remaining 140 cases, the erysipelas either originated in the wards, inde- 
pendent of operations, or outside of the institution, and were subsequently 
brought in, 24 of which were fatal,-the mortality being one-third greater in 
this latter class. 
Treatment.-Not the least important in this connection are prophylactic 
measures. Much may be done to prevent the appearance of erysipelas in 
hospital or private apartments. To this end the most rigid attention to 
cleanliness, ventilation, and drainage should be given. The personal clothing 
and bedclothes should be frequently changed; the dejections must be dis- 
infected and immediately removed, and all soiled dressings at once taken 
away; knives, scissors, dressing forceps, and sponges require to be thoroughly 
cleaned and immersed for a short time in carbolated water; and an ample 
supply of fresh air must be secured. Whenever a case is brought into or 
occurs in a hospital, the patient should be isolated at once, and placed as 
far as possible from the other inmates of a ward. The curative treatment 
may be considered under two heads, general and local. 
General treatment.-In the use of constitutional remedies the surgeon must 
be governed by the variety and tendency of the disease. In the very mild 
form, that in which the inflammation is confined to the skin and not attended 
with any marked constitutional disturbance, there is very little treatment 
required, other than to have the intestinal secretions corrected by the ad- 
ministration of five or six grains of blue mass, followed by a gentle saline 
cathartic. After the bowels have been acted on, a dessertspoonful of neutral 
mixture may be given every two hours, each dose containing one-thirtieth 
of a grain of morphia. This combination is not only an excellent febrifuge, 
but also allays nervous restlessness and promotes sleep. The diet should be 
light, so as not to tax the digestive organs, and should consist for the most 
part of milk or beef-tea; and the apartment must be kept well ventilated 
and at a temperature comfortable to the sensations of the patient. 
In the deeper variety of erysipelas (the cellulo-cutaneous, for example), in 
which both the local and the constitutional symptoms are more aggravated, 410 
ERYSIPELAS. 
a more active treatment will be demanded. A mercurial purge may be ex- 
hibited, which should be followed by the tincture of sesquichloride of iron, 
and quinia. 
The administration of iron in large doses (say twenty or thirty minims) 
every two or three hours, as directed by Hamilton Bell, who introduced the 
remedy into practice in 1851, is, in my judgment, of very doubtful propriety. 
I have obtained as satisfactory results by giving half the quantity. Quinine 
is a valuable drug in this disease, and may be administered in doses of two 
or three grains every two or three hours during the day. Nervous restless- 
ness is best allayed by giving one-eighth of a grain of morphia in a table- 
spoonful of the effervescing mixture once in two or three hours, or by ad- 
ministering four or five grains of Dover's powder once every four hours. As 
the tendency of the disease is almost always asthenic, it is necessary to sus- 
tain the system by food and stimulants, for which purpose milk, milk-punch, 
and concentrated beef-essence should be given with regularity and frequency. 
As a rule, it is much better to give a moderate quantity of such articles at 
one time and at intervals of an hour, than a larger amount at longer periods. 
The nausea and vomiting which sometimes usher in an attack of erysipelas 
are best alleviated by carbonic acid water, or by frequent draughts of hot 
water. When the tongue becomes dry and dark, and the signs of general 
prostration are present, a turpentine mixture with carbonate of ammonia will 
be strongly indicated. 
General blood-letting at one time occupied a conspicuous place in the treat- 
ment of erysipelas. Without pronouncing any judgment on the past, the 
circumstances which would justify the use of the lancet at present must be 
very exceptional. Local blood-letting, whether by cups or leeches, must have 
a very restricted application. In the early years of my professional work 
I frequently witnessed in idiopathic erysipelas the free use of the lancet, fol- 
lowed by nauseating doses of antimonials and saline purgatives. The patients 
were strong, robust country-people, and generally recovered, but, I suppose, 
got well in spite of the doctor,-as the convalescence was very slow. 
Emetics have been alternately extolled and condemned. If there is evi- 
dence of a loaded stomach or a torpid liver at the time the disease makes 
its appearance, a gentle emeti'c of ipecacuanha will be productive of good 
by removing a source of irritation or by exciting the biliary and cutaneous 
secretions. 
Purgatives, which for a long time played an important part among the 
revulsive remedies in erysipelas, frequently do good at the commencement 
of an attack; but when the intestines have been once cleared out their work 
is done, and any action on the bowels, othei1 than that of an occasional laxa- 
tive, does harm rather than good. 
Iodide of potassium, at one time strongly recommended by Professor J. 
K. Mitchell, does not appear to exercise any controlling influence over the 
disease. 
Mercurials.-By those who saw in every disease a biliary spectre, mercu- 
rials at one time were administered liberally during the course of erysipelas. 
That mercury possesses a peculiar power of correcting the secretions, and 
of course in this way of relieving the blood of deleterious matters, can 
scarcely be doubted; but I am disposed to believe that, except at the com- 
mencement of the attack, when a few grains of calomel or of blue mass 
should be given, preliminary to a saline cathartic, it may safely be dispensed 
with. 
Local applications.-On the subject of local applications the profession has 
been, and still is, very much divided, some extolling and others deprecating 
their employment. The advocates of topical treatment differ greatly as to the 
remedies best suited for the purpose. Liquids, ointments, oils, and powders 
have all in turn been recommended. Among these may be named plain 
water, or water medicated with astringent salts, as the acetate of lead or 
sulphate of zinc; some contending that these evaporating lotions should be ERYSIPELAS. 
411 
cold, and others that they should be used warm. Among oleaginous agents, 
Betz attached importance to lime-water and sweet oil,-a mixture to which 
Dr. J. Forsyth Meigs is partial. Solon used inunctions of fat; Velpeau, Ri- 
cord, Wallace, and others, mercurial ointment. Glycerin, from its known 
property of attracting moisture and thus relieving muscular tension, has 
been used by Griscoms. 
Higginbottom advised the topical application of a strong solution of nitrate 
of silver upon and around the inflamed surface. The tincture of iodine has 
been applied in the same manner. The power of limiting the inflammation 
has been claimed for the last two agents when painted over the skin beyond 
the limits of the affected surface. Tincture of sesquichloride of iron is 
anothei- remedy, which has been used and strongly recommended for its effi- 
cacy by Garretson. Recently, the hypodermic injection of dilute carbolic 
acid into the cellular tissue beneath the inflamed surface has been recom- 
mended by Hueter. The same surgeon has used tar, an article which for 
many years was employed by Dr. Coates, of this city. Among the powders 
employed with which to dust the inflamed surface are rye-meal, starch, and 
lycopodium. 
Pressure is a very old means of combating the inflammation of erysipelas, 
having been employed by Heister, and afterwards receiving the commendation 
of Bretonneau and the qualified sanction of Velpeau. The part, an arm, for 
example, was covered by a rollei* bandage, evenly applied from the fingers 
to the shoulder, and afterwards kept wet with water. The object was to 
moderate the inflammatory action by pressing a portion of the blood out of 
the vessels, and preventing the undue distention. In a number of instances 
the practice was followed by mortification of the limb, and as a result the 
method was abandoned. 
Other remedies might be mentioned, as camphor, oil of turpentine, hypo- 
sulphite of soda, boracic acid, etc. I have used almost all the remedies 
to which reference has been made, and I am compelled to confess that the 
results have been so conflicting and negative in their character that I seriously 
doubt the power of any local application to modify in the least the course of 
the disease. Making the largest allowance for the discrepancy of human 
observations, all, I think, that can be claimed for this class of remedies is 
the palliation of that sense of stiffness, heat, and pain which is generally a 
very unpleasant accompaniment of this affection; and with this object in 
view a solution of the acetate of lead (5ss of the salt to gvi of water), to 
which may be added two drachms of laudanum, has fulfilled most perfectly 
the indication. A thin piece of old linen cambric should be wet with this 
lotion, lukewarm, laid over the surface, and renewed as often as it becomes 
dry. 
Very different, however, is it with cases of deep erysipelas, where the sub- 
cutaneous cellular tissue is filled with the products of inflammatory infil- 
tration. Here the value of local measures becomes paramount: the danger 
consists not only in the death of the cellular tissue by pressure on the blood- 
vessels, but also in disorganization of the deeper structures. When, therefore, 
the inflamed part presents the hard, dusky, and brawny appearance so char- 
acteristic of this variety of the disease, it should be covered with a light 
flaxseed-meal poultice, and carefully inspected on each renewal of the same. 
Should the induration, pain, and swelling not begin to yield in twenty-four 
hours, the tension of the tissue must be promptly relieved by a number of 
incisions, from three-quarters of an inch to an inch in length, made over the 
most swollen parts, and carried boldly down to the deep fascia, taking care 
to avoid any large vessel which may lie in the region. This will relieve the 
tension by allowing the escape of the inflammatory transudation, and will 
thereby invite the resolution of the local disease. 
The manner of making these incisions must be determined by the locality. 
Over the extremities or upon the trunk they should run in the longitudinal 
axis of the limb or the body; on the scalp, somewhat oblique to the antero- 412 
BURNS FROM ARTIFICIAL AND SOLAR HEAT. 
posterior diameter of the head, so as to favor the gaping of the wound ; over 
the eyelid, parallel with the normal wrinkles, or in the direction of the fibres 
of the orbicularis palpebrarum muscle, in order to leave no visible scar. 
When the object is to open a way into the cellular tissue of the orbit, the 
puncture should be made beneath the palpebra, where the conjunctiva is 
reflected from the eyelid to the eye; and when operating on the face, the 
incisions are to be made in the course of the muscles of expression. On the 
trunk and extremities it is always better to make a number of short cuts 
rather than one long cut. As the vessels have been intensely congested, there 
sometimes follows quite a free bleeding, which, should it not cease sponta- 
neously, must be staunched by placing over the wounds compresses first 
wet with hot water and then squeezed dry, and binding them to the part 
with a roller bandage. 
After the incisions have been made, the poultices may again be applied, 
and continued for two, three, or more days, when they may be replaced by 
a warm-water dressing, and later by one of zinc ointment. When the in- 
duration is followed by a quaking or boggy feel, it is an evidence that the 
inflammation has culminated in suppuration, in which case free incisions 
must be made without delay, with a view to give exit to the unhealthy 
serum and pus, and also to furnish a way for the removal of the shreds of 
dead cellular tissue. These must be drawn away, as they separate, by the 
forceps, and the cavities or furrows syringed out at each dressing with a 
solution of permanganate of potash, of carbolic acid, or of sulphate of iron.* 
After the parts have thus been cleansed, poultices or warm-water dressings 
must be applied, covered with waxed paper or oiled silk. In some cases it 
will be necessary to pass a drainage-tube from one opening to another to 
prevent accumulations of matter. Twice a day it will be necessary to repeat 
this treatment of the wounds. As soon as the sloughs have been removed, 
the oxide of zinc ointment may be laid over the parts, and a roller applied 
with considerable firmness, so as to secure the adhesion of the skin to the 
subjacent parts. 
When the disease attacks the throat, relief will be obtained by the inhala- 
tion of the steam from a hot decoction of chamomile flowers, by scarifica- 
tion, and by the free application of a strong solution of nitrate of silver 
(forty grains to the ounce of distilled water) to the tonsils, half arches, and 
pharynx. 
Should the inflammation extend to the larynx, causing serious obstruction 
to the entrance of air, a careful exploration must be made with the finger, 
carried along the dorsum of the tongue, and, if oedema can be recognized, 
the part should be scarified by a curved bistoury, the edge of which can 
be shielded by being wrapped with a narrow piece of tape or by a strip of 
adhesive plaster, leaving about half an inch nearest to the extremity of the 
instrument uncovered. The finger will furnish the best director for con- 
ducting the knife to the offending point. In extreme cases laryngotomy or 
tracheotomy may be required. 
Practically, with regard to their effects, there is no difference between 
burns and scalds. Both are alike the result of a high degree of heat applied 
to the body. When the caloric is communicated from a solid body, as a piece 
of metal, it is called a burn; and when by a liquid or a vapor, as molten 
metal, boiling water, boiling oil, or steam, it is termed a scald. Burns, when 
caused by a heated solid body, are more circumscribed and extend deeper 
than when produced by liquids. The vast improvement in the arts and the 
multiplication of labor-saving machinery, with the ever-increasing industries 
and products of modern times, necessarily enhance the dangers of labor and 
Burns from Artificial and Solar Heat. 
* The strength of these injections may be stated as follows : permanganate of potash, three grains 
to the ounce of water; carbolic acid, one part of the acid to forty parts of water; sulphate of iron, 
four grains to the ounce of water. BURNS FROM ARTIFICIAL AND SOLAR HEAT. 
413 
render accidents of this kind more common. In large cities a very great 
proportion of all cases of burns among the poorer classes are occasioned by 
coal oil; and notwithstanding the almost daily notice of such accidents in 
the public prints and the danger attending the use of lamps, little heed is 
given to these warnings. 
As it is the duty of every organized community to conserve human life 
and health, I cannot conceive that it would be any exercise of arbitrary 
power, or savor in the least of sumptuary legislation, if it were rendered im- 
perative that all houses built within the limits of city jurisdiction should be 
provided with gas, so as to dispense with those highly-inflammable oils so 
generally used by the poor for the purpose of illumination. A similar pro- 
tection should be secured to those who are engaged in breweries and soap- 
manufactories, in which the most dreadful accidents of this nature occasion- 
ally occur. A netting might be stretched over the large tubs or caldrons 
containing the scalding liquids, which would in no way interfere with the 
proper manipulation of their contents and yet would render it impossible for 
operators, losing their equilibrium, to be precipitated into these great re- 
ceptacles. Those parts of the body which are most exposed, and on which 
the skin becomes rough and callous by constant contact with rough sub- 
stances, are rendered thereby quite proof against heat. In rolling-mills, 
forges, and smithies one is astonished to see the workmen handling with 
impunity pieces of hot iron which would blister an ordinary hand; and a 
quarryman will light his pipe from a live coal which he dallies with on the 
unprotected palm. 
Fluidity often determines the extent of a burn, from the facility with which 
the liquid spreads over the surface: thus, boiling water, being less consistent 
than boiling oil, will involve a larger extent of surface, though the latter, from 
the manner in which it clings to a part, will inflict a deeper scald. Metals of 
the same temperature produce different degrees of burning, according to the 
readiness with which they part with their caloric. Volatile substances, like 
alcohol and ether, though very inflammable, are yet so rapidly consumed that 
their effects are superficial. 
Burns have been variously classified. Sometimes this classification is based 
on the results of the ensuing inflammation, as suppuration, ulceration, and 
sloughing; at other times on an anatomical basis of tissue-planes, according 
as the skin, superficial fascia, muscles, and bones are implicated. 
Dupuytren's division was expressed by degrees, six in number. In the 
first degree the injury consists only of an erythematous inflammation of the 
skin; in the second, of inflammation with vesication; in the third the entire 
cuticle and a portion of the true skin are destroyed; in the fourth the entire 
thickness of the skin is destroyed, the burn extending into the subcutaneous 
cellular tissue; in the fifth the superficial muscles are included in the damage; 
and in the sixth the deeper muscles, the bones, and, indeed, all the components 
of the limb, are involved. 
Professor Gross adopts a more simple and better division,-that of simple 
and complicated burns; but as the most serious complication of internal 
organs may, according to this arrangement of the subject, follow a simple 
burn, I prefer to treat this subject under the same division as that employed 
in frost-bite, namely, 1st, burns followed by simple redness; 2d, burns followed 
by vesication, with or without ulceration; 3d, burns followed by sloughing. 
1st. Inflammatory redness, with or without vesication.-This is the result of the 
momentary contact of a hot solid, liquid, or gaseous substance with the skin. 
It may be either circumscribed or diffused. The impression made on the cuta- 
neous nerves, and, through them, on the vaso-motor branches of the vessels, is 
immediately followed by redness and slight swelling, and sometimes by minute 
vesicles,-the first from the sudden dilatation of the capillaries, and the second 
from the transudation of serum into the skin. These changes are accom- 
panied by a burning, smarting pain. When of limited extent, this, along 
with the redness and swelling, subsides, and is followed perhaps by a slight 414 
BURNS FROM ARTIFICIAL AND SOLAR HEAT. 
desquamation, leaving the parts very much as they were before the applica- 
tion of the irritant. 
2d. Inflammation, with vesication and ulceration.-In addition to the symp- 
toms present in the first variety, the transudation not only occupies the rete 
Malpighii, but also finds its way to the surface, raising the'cuticle into vesicles. 
These may be small, distinct, and numerous, or they may be large, confluent, 
phlyctenular bags or blebs. The serum which they contain is either cleai' 
or bloody, according to the severity of the inflammation. Where the fluid 
escapes from the vesicles, through either a spontaneous or an artificially-made 
opening, the serum drains away, and the devitalized cuticle dries up and falls 
off, or is displaced by a rapid reproduction of new cells from below, the skin 
assuming gradually its ordinary appearance. The pain is of the same nature 
as that experienced in the first variety, namely, smarting and burning, but 
is rendered much more severe when the raw surface under the blisters is 
exposed to the stimulating influence of the air. The vesicles after their 
rupture sometimes have superficial abrasions, which degenerate into shallow 
ulcers, the surfaces of which are covered with pus and fibrin, imparting a 
stringy character to the suppuration, and giving to the burned region a red, 
raw, granulated appearance. A burn of this kind becomes intensely painful, 
with great nervous irritability. This is a consequence of the exposed condi- 
tion of the terminal loops of the skin-nerves. 
3d. Inflammation following sloughing.-Under this head are included all cases 
of burns in which the vitality of the parts is destroyed, whether skin, fascia), 
muscles, or bones. The eschar which results may be white, yellow, gray, or 
a charred black mass. When the injury penetrates beyond the integument, 
it is generally in cases where the unfortunate victim is confined in the fire 
or exposed to steam, as in the case of engineers in railroad or steamboat ac- 
cidents. Such portions are separated in the form of sloughs by the processes 
of inflammation and suppuration, the resulting ulcers being exceedingly dif- 
ficult to heal, and not uncommonly producing cicatrices which cause, by their 
contraction, the most horrid deformities. 
Constitutional signs.-Following the local injury there is generally more or 
less constitutional disturbance, the severity of which may be measured by 
the superficial extent of the burn, by its location, and by the age of the pa- 
tient. A foot or a hand may be reduced to a black charred mass and yet 
cause less general perturbation of the system than a burn of the simplest 
degree of wide-spread extent. A burn of the scalp, face, or chest is much 
more serious than one situated over other regions. Children also, from the 
extreme irritability of their nervous systems as compared with adults, endure 
badly the depressing effects of burns. 
The constitutional effects of burns may be included under three heads,- 
shock, inflammatory fever, and exhaustion. 
Shock.-In severe cases the pulse is feeble and frequent, the respiration 
embarrassed, the surface cold; there are shiverings, great restlessness, sick- 
ness of stomach, and an unquenchable, agonizing thirst. "For the love of 
God, dear, dear friends, give me water, water, cold water! Why will you 
deny such a pittance to a poor, dying wretch ?" continually cried a negro 
woman, who was fast sinking under a dreadful burn, as I passed her bed in 
going, one morning, my hospital rounds: she had the cup to her mouth while 
uttering the touching appeal. Martyrdom at the stake, I take it, is some- 
thing more than a mere sentiment, as some persons would have it. 
Many persons never recover from the shock, but sink into a hopeless col- 
lapse, and die within the first twenty-four or thirty-six hours. The blood 
under such circumstances accumulates in the internal organs, producing in 
some instances intense congestion of the brain and its meninges, and in 
others a similar condition of the organs of the thorax or the abdomen, not 
unfrequently accompanied with effusion. 
2d. Inflammatory fever.-Should reaction occur, inflammatory fever of a 
continued type sets in, exhibiting a tendency to produce inflammation in BURNS FROM ARTIFICIAL AND SOLAR HEAT. 
415 
those organs which suffer during the stage of shock from congestion. The 
severer cases of this fever continue from one to two weeks, during which 
time many persons die from bronchitis, pneumonia, peritonitis, gastro-enter- 
itis, arachnitis, and ulceration. Not a few young subjects perish from 
tetanus. Among these secondary accidents are ulceration and perforation of 
the duodenum, first noticed by Curling. The lesion, commencing as an in- 
flammation of the mucous membrane, extends rapidly through all the coats 
of the intestines,-death following, either from extravasation of the intestinal 
contents, creating peritonitis, or from hemorrhage. This ulcer occurs about 
once in every four or five fatal cases of burns in which the patient survives 
the stage of shock: though in exceptional instances it may appear as early as 
the fourth or fifth day, yet the usual period for its development is about the 
tenth day following the stage of reaction. 
There are no symptoms which are certainly diagnostic of the presence of 
duodenal ulcer. The sudden invasion of pain in the left hypochondriac 
region, vomiting of blood, strained stools, and abdominal tenderness, will form 
reasonable grounds for conjecturing its existence. No satisfactory explanation 
has yet been given why this particular portion of the intestinal tract should 
be more prone to perforation than another; there is no evidence to prove 
that the duodenal or Brunner's glands are capable of supplementing defects 
of, or exchanging offices with, the perspiratory glands of the skin, or that 
when the latter are rendered helpless by a burn of the surface the former 
are overtasked. This was the explanation given by Curling. Nor does the 
doctrine of capillary embolism, advocated by Feltz and others, offer any 
better solution of the problem. For, if the blocking-up of the minute 
branches of the pancreatico-duodenal artery explains this structural change, 
why should not similar perforations be seen in other sections of the intestinal 
canal, where inflammation of the mucous membrane and embolism are quite as 
frequently present ? 
In addition to the fever of irritation, another element of exhaustion is en- 
countered, in the suppuration which attends the separation of the devitalized 
tissues, and in the course of which the patient frequently dies, worn out by 
exhaustion, or as the result of secondary inflammation of internal organs, 
notably of those within the chest. About one-third of all fatal cases occur- 
ring during the separation of sloughs and the attending suppuration die from 
pleuro-pneumonia and its sequelae, as sero-purulent accumulations in the 
pleural cavity, and red and gray hepatization of the lung-tissue. Why the 
contents of the thorax are selected, as a rule, by the disease, rather than those 
of the abdomen or the cranium, is a question not easily answered. The cu- 
taneous nerves are all exciters of respiration; and a certain degree of aeration 
is also effected through the vast capillary net-work of vessels which inter- 
penetrate the skin. The sudden interruption or disturbance of the relation 
between these two functions (that of the skin and that of the lungs) which 
results from the destructive operation of a burn or a scald may be no incon- 
siderable factor in explaining the frequency with which the lungs suffer 
during the period under consideration. Again, the frequency of pleuritis 
and pneumonia during the winter months shows a very significant inter- 
dependence between the cutaneous and the respiratory function. 
Prognosis.-The circumstances to be taken into consideration with refer- 
ence to the probable issue of a burn are the same as those which have been 
noticed in connection with the grades of constitutional disturbance. 
The danger is in proportion to the extent of surface involved, however 
slight may be the cutaneous inflammation. When it exceeds more than one- 
third of the superficies of the body, it is an old and true observation that 
recovery rarely takes place. I do not remember, certainly, more than two 
exceptions to this rule in my own experience. Deep burns which are local 
become serious in proportion to the amount of subsequent suppuration. In 
burns over the chest or the abdomen, the danger of intra-thoracic and ab- 
dominal inflammation is augmented; and so, when on the face or the head, 416 
BURNS FROM ARTIFICIAL AND SOLAR HEAT. 
the risk of meningitis or cerebritis is increased. The very young and the 
aged are much more likely to succumb to a burn or scald than persons in 
middle life. The largest number of deaths after burns or scalds (over 50 
per cent.) occur during the first twenty-four hours following the accident; 
the next most fatal period is between the eighth and the thirteenth day. 
Of 305 cases of burns or scalds received into the Pennsylvania Hospital 
between the years 1859 and 1879, 144 died and 161 recovered; and of the 
144 deaths, 111 were from shock, and 33 from secondary inflammation of 
internal organs and from exhaustion. Of the 111 cases dying from shock, 
77 perished within twenty-four hours, 13 
with in forty-eight hours, 8 within seventy- 
two hours, 7 within ninety-six hours, and 6 
within one hundred and twenty hours. Of 
the 29 deaths which occurred from secondary 
causes, 11 were within nine days, and the re- 
maining 18 between the thirteenth and the 
one hundred and thirteenth day; 4 of the 33 
deaths were from tetanus, occurring respec- 
tively on the ninth, the twelfth, the four- 
teenth, and the fifteenth day. Even when the 
subject of a severe burn escapes with his life, 
there remains a liability to a variety of 
serious consequences from the resulting cica- 
trices causing unsightly deformities, accord- 
ing to the seat of injury,-as eversion of 
the eyelids and contortions of the lips and 
mouth; drawing the head to one side (Fig. 
1236) or the chin towards the sternum (Fig. 
1237) ; uniting the fingers; tying the arm 
to the side, causing contractions of the limb 
(Fig. 1238) and anchylosis of the joints. These cicatricial scars, at first red, 
Fig. 1236. 
Deformity following a burn of the face 
and neck. 
Fig. 1237. 
Fig. 1238. 
Chin drawn towards the sternum by the cicatrix following a burn. 
Arm flexed and bound to the side by 
an extensive cicatrix following a burn. 
become after a time abnormally white, puckered, and elevated into ridges. 
They frequently undergo a keloid transformation, having a blue or lilac color, BURNS FROM ARTIFICIAL AND SOLAR HEAT. 
417 
and sometimes becoming very sensitive. Malignant disease is occasionally 
developed in the cicatrix of an old burn. 
Treatment.-The indications are to relieve shock, to alleviate pain, to pre- 
vent secondary inflammation of internal organs, to favor the separation of 
sloughs, to support the general system, and to prevent deformities. To carry 
out these objects, the management of a burn or a scald necessarily involves 
constitutional and local treatment. 
Constitutional Treatment.-The shock which attends severe cases of 
burn or scald demands immediate attention. Opium in some form is invalu- 
able, and must be given in doses sufficiently large and frequent to allay the 
dreadful distress which patients experience. Stimulants, w'hen the collapse is 
well marked, will also be required, as brandy, whisky, carbonate of ammonia, 
and wine, but when the symptoms of depression are not very pronounced it 
is better to abstain from their administration, for they will only add to the 
violence of the reaction. When there is difficulty in swallowing, the anodynes 
can be used hypodermically, and the stimulants administered by the rectum. 
External warmth must be applied to the spine, extremities, and epigastrium. 
This is most conveniently done by means of heated bricks or bottles of hot 
water rolled in pieces of flannel, or by hot-water bags. When reaction sets in 
there follows the danger of internal inflammations. As these are probably de- 
pendent, to some degree at least, on the deranged functions of the secretory 
apparatus of the skin, it should be the aim of the practitioner, as much as 
possible, to keep in action those organs which are capable of performing 
a vicarious work for the skin, namely, the intestines and the kidneys. A 
saline laxative from time to time will increase the activity of the intestinal 
glands; and fifteen or twenty grains of bicarbonate of potash dissolved 
in half a pint of water, and drunk in the course of twenty-four hours, will 
stimulate the renal organs. During the period of suppuration it will be 
necessary, by tonics and good food, to sustain the general strength. Should 
tetanic symptoms threaten or convulsions occur (not an uncommon compli- 
cation in young subjects), they must be combated, the former by anodynes, 
as laudanum or chloral, given in conjunction with bromide of potassium, 
and the latter by hot foot-baths and bromide of potassium. Vomiting is 
sometimes a troublesome attendant of burns or scalds, and is best corrected 
by small draughts of hot water, or by lime-water, or, should these means 
fail, by oxalate of cerium, or diluted prussic acid, along with very minute 
doses of morphia. Diarrhoea, when present, is best managed by full doses 
of subnitrate of bismuth and opium. 
Local Treatment.-The profession has been somewhat divided as to the 
manner of dealing with the local inflammation resulting from burns, some 
advocating the use of sedative applications, such as cold, and others the use 
of stimulating agents. The nature of the local applications must be deter- 
mined by the depth and the extent of the burn. When the injury is a slight 
one, such as frequently occurs from unwittingly taking hold of a piece of hot 
metal with the fingers, or from overturning a small vessel containing hot 
water, common sense will lead any one, instinctively, to apply cold; and 
nothing so promptly gives relief as plunging the part into cold water, or 
enveloping it with wrappings of old linen and keeping it wet. The addition 
of a little laudanum to the water produces a very soothing effect. The effect 
of cold is enhanced by elevating the part, when it is feasible, so as to lessen 
the amount of blood in the inflamed tissue. 
After persisting in these measures until the smarting, burning pain is 
lessened, a firm and evenly-applied roller will supply a useful support to 
the vessels, and favor the resolution of the inflammation. When the burn 
includes a wide extent of surface, the application of cold is usually ob- 
jectionable, as by lowering the temperature of the skin and repelling the 
blood from the cutaneous vessels the chilliness and shock are increased, 
as well as the danger of secondary internal inflammations. Under these 
circumstances, covering the burned surface with pieces of old linen smeared 
vol. ii.-27 418 
BURNS FROM ARTIFICIAL AND SOLAR HEAT. 
with benzoated oxide of zinc ointment, and enveloping the whole with a 
layer of cotton batting, constitutes, in my experience, the most satisfactory 
dressing. Dupuytren was partial, in burns of a superficial nature, to the 
use of a solution of Goulard's extract, applied by moistening pieces of linen 
with the liquid. Where vesicles or phlycteena are present, they should be 
punctured on a level with the common surface, and their contents carefully 
pressed out, but without detaching the cuticle, which should be gently flat- 
tened down before the application of the zinc ointment. There should alsor 
in such cases, be sheets of waxed paper interposed between the linen on 
which the ointment is spread and the cotton batting. The contact of the 
atmosphere with the raw surface of a burn is exceedingly irritating; the 
cotton renders the dressing impervious to air, and when it becomes moist- 
ened with the discharges it can be withdrawn with the minimum of injury 
to the abraded surface. Burns of the degree under consideration should 
not be dressed oftener than is absolutely necessary: once in three or four 
days may be quite sufficient, this being determined by the amount and the 
nature of the discharges. An offensive odor is always an indication for the 
renewal of the dressings. 
Great injury and pain are often inflicted by removing the clothing from 
persons who have sustained a severe burn. Large sheets of the cuticle are 
sometimes torn off in this way, leaving a raw, sensitive, and exposed surface. 
When, therefore, by gentle manipulation, a shirt or a stocking or the leg of 
the trousers cannot be readily disengaged from the blistered surface, it will 
be better to apply cold water until this can be accomplished. 
Not unfrequently the burned part will be found covered with flour or some 
other powder, one of the popular domestic remedies for this class of injuries. 
The discharges becoming incorporated with these materials form a hard 
crust, the forcible separation of which from the surface of the burn is calcu- 
lated to do much harm. Where such a crust has formed, it should be al- 
lowed to remain until the detachment takes place spontaneously. This may 
require some time; but the surgeon will often be rewarded for the non-in- 
terference by finding that cicatrization has been completed beneath the scab. 
A great variety of other agents are in use. The Carron oil, consisting of 
equal parts of linseed oil and lime-water, and named from the Carron Iron- 
Works, in Scotland, where the remedy was much employed among the 
operatives for the treatment of burns, is still in very general use. It is a 
soothing and valuable mixture, having only the objection of an offensive 
odor, which is greatly lessened, and without detracting much from its value, 
by substituting olive oil for the linseed oil. Professor Gross speaks favorably 
of white lead, used in the form of paint, and laid over the part with a soft 
brush: it is quite as efficacious as the Carron oil, and is a much more agree- 
able application. Dr. Packard employs fresh lard. Turpentine and oint- 
ments or oils containing a small quantity of carbolic acid have also their 
advocates. When there is a raw and painful surface, the addition of carbolic 
acid to oxide of zinc ointment, in the proportion of two or three grains of 
the former to an ounce of the latter, has a very soothing effect, on account 
of the anaesthetic properties of the acid. In severe burns or scalds, where 
there is more or less sloughing, exposing the rete Malpighii of the skin, 
stimulating applications will be found most useful, and among these the 
ordinary resin ointment, adding to each ounce one drachm of turpentine 
(Kentish ointment), I find to answer every purpose. Dr. Read, of Consho- 
hocken, Pa., besides the turpentine, adds a small quantity of phenol sodique 
to the resin ointment, a combination of which I can speak favorably from 
experience. Dr. Addinell Hewson advocates wet clay. 
When the vitality of the integument has been destroyed, the parts being 
burnt into a crisp, the sooner its separation as a slough is effected the better; 
and with this view, after using for a few days a lotion of lead-water and 
laudanum, applied by wetting old pieces of linen with the liquid and wrap- 
ping them round or placing them over the damaged part, we may resort BURNS FROM ARTIFICIAL AND SOLAR HEAT. 
419 
to flaxseed-meal poultices, renewed three times every twenty-four hours. 
As soon as suppuration has been well established and the dead tissue begins 
to loosen, the devitalized fragments must be picked away, the parts thoroughly 
cleansed with deodorizing washes, as permanganate of potash, diluted alcohol, 
or Labarraque's solution, and the poultices rendered stimulating by smearing 
over their surface a quantity of the compound resin or Kentish ointment. 
After the dead tissue has all been removed and granulation has commenced, 
special attention must be given to the treatment of the ulcers. 
Treatment of the caloric ulcer.-If the granulations are indolent, they may 
be stimulated with sulphate of copper or nitrate of silver; if redundant, the 
latter agent, if freely applied, aided by pressure with adhesive strips, will 
serve to repress their exuberant growth. Though no remedy will so modify 
the character of the granulations that the cicatrix will lose the property of 
contraction, it has appeared to me that a solution of caustic potash (three 
grains of the alkali to one ounce of water), applied lightly over the granula- 
tions every day or two during the process of healing, does in some degree 
lessen this tendency. Generally we endeavor, by approximating the sides of 
a granulating sore, to render the cicatrix as small as possible. Not so in the 
ulcer following burns: here the object is to enlarge the extent of the cicatrix, 
so as to provide for its subsequent shortening. Accordingly, in burns of the 
extremities, near the articulations, and on the aspect of flexion, the limb must 
be maintained in an extended state by the addition of a properly-constructed 
splint. If the burn or scald involves the axillary region, the arm must be 
preserved in the posture of abduction; if the neck, the head must be extended, 
to prevent the chin from bearing down towards the breast. When the hands 
or the feet are scalded, the opposing or raw sides of the fingers or toes must be 
kept asunder by the interposition of strips of oiled lint, and rolls of the same 
should be fitted into each interdigital cleft. If these points are neglected, 
webbed fingers or toes will be the result. When the ulcer is situated at the 
margin of the outlets of the body, as the nose, mouth, etc., appliances of lint 
or hard rubber should be introduced into these openings. It is necessary to 
use these mechanized appliances not only during the progress of healing, but 
also for several months after the completion of that process. 
Treatment of cicatrix.-We have in the process of skin-grafting a most valu- 
able resource to remedy contraction, and one which should never be omitted. 
In this way it is possible to secure not only the cicatrization of ulcers which 
otherwise would not heal at all, but also to obtain a cicatrix free from the vicious 
propensity to create deformity. The cicatrix following a burn or a scald, if 
not too old, may, under the influence of mechanical measures (as the traction 
of a weight suspended, for example, from a contracted leg, or an anterior 
splint with a Stromeyer screw applied to the arm), be somewhat elongated. 
When, however, the new tissue becomes ancient, or of six or eight months' 
standing, little, if any, advantage can be expected from such expedients. 
Under these circumstances, and when contraction seriously interferes with 
the functional use of a part, the question of correcting the evil by an opera- 
tion must be considered. The simple division of the cicatricial band can be 
productive of no permanent benefit, since the gap which results will be filled 
up by granulation-tissue of the same nature as that which has been severed. 
No operation can be of any permanent benefit which does not substitute 
healthy skin for the inodular tissue, and there are only two ways in which 
this can be done, namely, either by lateral approximation or by transplanta- 
tion of sound skin. Whichever of these methods is adopted, the surgeon 
must make his incisions so as to include, both in width and in depth, the 
cicatricial tissue. 
Relief of cicatricial contraction by lateral approximation of sound skin.-This 
plan is applicable only to cases in which the inodular tissue is narrow and 
prolonged to a point. The operation consists in making an incision in the 
sound skin on either side of the tongue-shaped prolongation of inodular 
tissue, and through the entire depth of the integument, dissecting up the 420 
FROST-BITE, CHILBLAIN, PERNIO. 
cicatrix and sliding it back. The triangular chasm which results is now to 
be closed by loosening up the integument on each side and bringing the 
edges together. Fig. 1239 illustrates the principle of this operation. 
When the cicatrix is very extensive, the 
evil may still be corrected by the transplanta- 
tion of sound tissue from the vicinity of the 
scar. Thus, in the neck, a flap of integument 
may often be obtained from the front of the 
chest or from the shoulder; and when the 
scar is on the skin or the lower border of the 
face, a healthy flap can be raised from the 
neck. Even should the gap left after the 
removal of the cicatrix be only imperfectly 
closed by the new flap, much will have been 
gained in lessening the amount of inodular 
tissue, and the remaining part of the ulcer 
may be treated with skin-grafts. The rules 
governing these procedures are the same as 
those prescribed under the head of plastic 
operations. 
Amputation may become necessary after 
burns, where a limb is found so hopelessly 
distorted that it constitutes a positive hin- 
derance to movement, or where the bones 
have been exposed by sloughing and the patient's strength is failing under 
an exhausting suppuration. 
Fig. 1239. 
The tongue-shaped cicatrix which flexed 
the forearm has been dissected and slid back, 
and the sutures inserted ready for approxi- 
mating the sides of the wound. 
Frost-Bite, Chilblain, Pernio. 
Severe cold causes a peculiar inflammation of the skin commonly described 
as frost-bite, the effects of which are designated chilblains and pernio. The 
portions of the body which generally suffer are those farthest removed from 
the centre of the circulation, as the toes, the fingers, the tips and lobes of 
the ear, and the end of the nose. Those who suffer most from this affection 
are persons who, by their occupations, are compelled to be much in the open 
air during the winter months, as soldiers, sailors, teamsters, policemen, and 
out-door laborers in general. 
A low temperature, if the air is dry, is much less likely to produce chilblain 
than the same temperature or even a somewhat higher temperature when 
the atmosphere is loaded with moisture. Moisture is particularly favorable 
to frost-bite: a wet foot or one which perspires very much is less able to 
resist the evil effects of cold than a dry one. 
Whatever tends to diminish the activity of the capillary circulation consti- 
tutes a predisposing cause of chilblain. Among such causes we may enumerate 
a feeble heart, scantiness of raiment, both of the body and of the extremities, 
deprivation, fatigues, and alcoholic stimulants. The popular idea that alco- 
holic stimulants constitute a means of resisting the injurious operation of a 
low temperature is utterly unfounded. The excitement which they tem- 
porarily produce is followed by a corresponding depression of nerve-energy, 
leaving the skin even more helpless against the effects of cold, and the mental 
stupor which they induce renders the person given to such indulgence less 
quick to appreciate the danger to which he is exposed. 
Varieties.-There are four degrees of chilblain: 1st, simple redness or in- 
flammation of the part; 2d, vesication ; 3d, ulceration; 4th, mortification. 
1st. Simple inflammation.-In this degree of frost-bite there are heat, red- 
ness, itching, and slight swelling. When the inflammation is more strongly 
pronounced, these symptoms are all aggravated; the color is purple or bluish, 
the heat burning, the itching intense, the pain severe, the swelling conspicuous; 
all of which symptoms are intensified by the warmth of the bed or when the 
patient approaches the fire. These paroxysms of suffering, though generally FROST-BITE, CHILBLAIN, PERNIO. 
421 
greatly influenced by the state of the weather or the season of the year, occa- 
sionally recur daily or even twice a day, and sometimes with a singular 
regularity in their periodicity. 
2d. Inflammation with vesication.-In this variety, in addition to the redness, 
there are present one or several vesicles which are filled with a blood-stained 
serum. These vesicles, after the discharge of their contents, may dry up 
and be replaced with a sound epithelium, or they may degenerate into ulcers, 
forming the third degree of the disease. 
3d. Ulcerative chilblains.-The ulcer or ulcers succeeding the vesication 
have an unhealthy aspect, discharge a thin, serous, ichorous pus, and are 
associated with a marked diminution in the sensibility of the parts. Nor do 
they always remain superficial, but, on the contrary, destroy the subjacent 
parts, even to exposing the periosteum and the bones. 
4th. Mortification.-In this last degree of frost-bite the redness is followed 
by the appearance of blebs filled with bloody serum, and the color of the 
surface changes to a blue and then to a cherry red, which betokens the 
certain dissolution of the parts. 
Action of cold.-The first effect of cold on the body is stimulating. A keen, 
frosty air heightens the color of the cheeks and brings a pleasant glow over 
the face, and the same to the ungloved hand, as the blood rushes into the 
capillary vessels. In this respect heat and cold operate alike. If the ex- 
posure continues and the cold is severe, the blood recedes from the surface, 
the temperature falls, and the part becomes pale, shrunken, stiff, numb, and 
insensible. If now the hand or the foot in this condition is placed in warm 
water, or held to the fire, a violent reaction follows; the parts begin to redden, 
tingle, burn, and finally to ache. Gradually the stiffness passes away, the 
equilibrium of the circulation is restored, the sensibility returns to its normal 
state, and no evil may result. Should, however, the reaction be so violent as 
to overstrain and paralyze the engorged capillaries, there follow undue red- 
ness, transudation of serum, giving rise to some swelling, and disordered 
nerve-action, as shown by the severe burning, itching, and pain experi- 
enced, which phenomena, collectively considered, constitute frost-bite. The 
more aggravated forms of the disease, namely, those accompanied by ulcera- 
tion and mortification, are expressions of a more intense degree of inflam- 
mation. 
Besides these local effects of cold there are others which are general, 
affecting the system at large, and which are attended by a gradual depres- 
sion of the functions of organic and animal life. The surface becomes cold, 
stiff, and numb, the circulation feeble, and the respiration scarcely noticeable, 
while a sense of drowsiness steals over the person so irresistibly as to demand 
an almost superhuman effort of the will to resist it. Should the unfor- 
tunate victim, failing to appreciate his danger, surrender to this treach- 
erous feeling of slumber, he is probably lost: it is the icy sleep of death, 
which locks up the vital fluids and stops the wheels of life. Larrey, in his 
" Memoirs," gives a graphic description of the effects of severe cold on the 
French army during the disastrous retreat from Russia after the fall of 
Moscow. The remarkable power of man to resist the intense cold of high 
latitudes has been well exemplified in the reports given by Arctic explorers, 
among the most eminent of whom of our own country are the late Dr. Kane 
and Dr. Hayes. 
Treatment.-The treatment of frost-bite is preventive and curative. To 
avoid the ill effects of a low temperature, the body and extremities should be 
warmly clad. Tight-fitting boots or gloves are particularly dangerous, as they 
not only embarrass the circulation and leave no space for a stratum of warm 
air, but also prevent motion of the parts encased. When, after long exposure 
to cold, a part is threatened with frost-bite, it is of primary importance that 
the circulation and the sensibility be very gradually restored: accordingly, 
the application of heat is to be deprecated. The benumbed and insensible 
parts should be rubbed with snow or finely-broken ice, or, in the absence of 422 
FROST-BITE, CHILBLAIN, PERNIO. 
these, they may be placed in cold water for a short time, and, after being 
removed, briskly rubbed with a woolen cloth moistened with alcohol. In this 
way, the reaction being very cautiously established, the danger of frost-bite 
may be averted. 
When the whole body is partially frozen, the same caution must be observed 
with reference to the sudden change from cold to heat. The person must be 
first brought into a room without fire, and all wet or damp clothes should be 
removed and dry ones substituted. The limbs and body are next to be sub- 
jected to continuous rubbing with the hands or a piece of soft woolen cloth. 
The respiration must be sustained, when necessary, by holding to the nose 
some volatile preparation of ammonia and by keeping up artificial breathing. 
Warm drinks, as coffee, tea, or wine-whey, will assist in stimulating the heart, 
and, when the patient cannot swallow, milk, with a little brandy, may be 
thrown into the bowel by injection. When the respiration and circulation 
have been measurably restored, the temperature of the room may be cau- 
tiously raised; and, in order that the reaction maybe quickly established, 
resort should be had to friction with snow or ice-water, and, as soon as the 
natural temperature returns, for these should be substituted something of a 
more stimulating nature, as soap liniment or alcohol, so as to impart tonicity 
to the walls of the capillaries and prevent congestion. 
The curative treatment for chilblain is very unsatisfactory. When the 
disease is slight, consisting only of some undue redness or a mottled condition 
of the skin, with itching and burning, relief may be obtained by the use of 
stimulating applications. Those which are commonly employed are turpen- 
tine, tincture of iodine, dilute carbolic acid (one pint of the acid to nine pints 
of water), soap liniment, or the latter with tincture of cantharides (two parts 
of the tincture to six parts of the liniment), generally known as Wardrop's 
liniment. Venice turpentine, mixed with a little lime-water and volatile lini- 
ment, will often give very prompt relief from the severe burning itch which 
is likely to harass the patient as soon as the feet or the hands become warm 
in bed. The use of dilute nitro-muriatic acid is also attended with good effects. 
No one remedy, however, will answer in every case, and the surgeon must try 
one after another until the proper one has been discovered. Even after the 
symptoms subside they are liable to reappear on slight changes of tempera- 
ture, so that many persons are never entirely freed from periodical attacks of 
the inflammation. 
When vesicles form, a strong solution of nitrate of silver (fifteen grains to 
half a drachm of distilled water), or a mixture of collodion and Venice tur- 
pentine, may be brushed over the part with advantage. 
The ulcers which result from frost-bite are also quite intractable to treat- 
ment : they should be touched with a crayon of nitrate of silver or sulphate 
of copper, and afterwards covered either with a strip of soap or adhesive 
plaster. Penciling the surface with an ointment of iodoform and gallic acid 
(three parts iodoform, one part gallic acid) will be found advantageous; and 
good effects also follow a light application of acid nitrate of mercury. 
When the vitality of the part is destroyed, decomposition sets in, and the 
same treatment will be indicated as in mortification from other causes. Fer- 
menting poultices are to be applied, that the process of separation may be 
hastened. Any fetor which is present should be destroyed by the use of 
permanganate of potash, nitrate of lead, oi- chlorinated soda. 
Sloughs, as soon as it is feasible, are to be removed, and when the line of 
limitation between the dead and living tissues is well established, should the 
case be one for amputation and the general condition be favorable, the opera- 
tion must be performed. It is thought by some that persons suffering from 
mortification as a consequence of frost-bite are peculiarly liable to pyaemia; 
but this opinion has certainly received no support from what is observed in 
American hospitals. While attending to local treatment, the general system 
must not be neglected. It will require to be liberally supported by nourishing 
food and the use of tonics. LIGHTNING-STROKE. 
423 
Sunburn. 
Exposure to the sun's rays for any considerable length of time will fre- 
quently cause a peculiar kind of burn in persons possessing a delicate skin. 
Women are more prone to such cutaneous irritation than men, and the parts 
which suffer most are the face, neck, and arms. 
The skin becomes red, painful, and swollen, and sometimes vesicles appear. 
In a few days thin, exanthematous crusts form, become fissured, and are fol- 
lowed by a free desquamation. 
As a prophylactic measure, protecting the parts most exposed to the sun 
by clothing, veils, and umbrellas will enable most persons to escape the irri- 
tating effect of solar heat. Cosmoline and vaseline may also be smeared over 
the skin with advantage. To relieve this inflammation when once present, 
nothing answers the purpose better than these same articles, to which may 
be added benzoated oxide of zinc ointment. 
The few writers who have observed injuries of the body caused by light- 
ning describe them as being often of a mixed character, and consisting of 
shock, cerebral concussion, and burn. Frequently the electric stroke is suf- 
ficiently intense to produce instantaneous death; or it may cause such a 
disturbance of the brain as to induce paralysis of the limbs, or the loss of 
special sense. The traumatic effect of the electric fluid is often seen in the 
surface of the body being scorched; and Stricker has figured certain arbores- 
cent lines ■which are represented as witnessed on the body in some fatal cases 
of this injury. When sudden death follows a stroke of lightning, the blood 
remains uncoagulated and the heart empty. In slight cases of stroke, when 
the patient is momentarily stunned, but soon regains his mental equilibrium, 
nothing more is required than to preserve for a short time the horizontal 
position. In severe cases, where there are only slight evidences of animation, 
external warmth and artificial respiration must be maintained. The paralysis 
which occasionally follows this injury is not regarded as altogether hopeless, 
many cases recovering after a long time. Galvanism and strychnia are rem- 
edies which have been employed in such cases. 
Lightning-Stroke. CHAPTER XX. 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Under this chapter will be considered all those casualties and diseases 
which affect the penis, the scrotum, the testes, the spermatic cord, the pros- 
tate gland, the bladder, the urethra, and the kidneys. 
Injuries and Diseases of the Penis. 
Injuries of the penis may be divided into those affecting the integument, 
those affecting the body, and those affecting the urethra. 
Wounds of the Integument.-These may be incised, lacerated, contused, and 
gunshot. 
Incised wounds bleed freely, but rarely demand the use of ligatures. Theii' 
edges should be brought together by interrupted sutures, and afterwards 
dressed by enveloping the organ in a piece of old linen wet with simple 
water. These wounds usually heal very kindly. 
Lacerated wounds are sometimes caused by persons falling upon hooks or 
becoming entangled in machinery. The fraenum is not unfrequently torn 
during coitus, and the resulting hemorrhage is sometimes very profuse and 
prolonged, and may demand the application of a thread. If the vessel is not 
readily isolated, the oozing surface may be gathered up with a forceps, and 
a thread placed round the mass, as in tying the neck of a sac. Other lacer- 
ations it will be proper to treat in the same manner as incised wounds, by 
interrupted sutures, so as to counteract the tendency to retraction. Luke- 
warm water is the best subsequent dressing. 
Contusions of the integument of the penis frequently result from kicks, 
from falls astride fences, wheels, etc. Extensive diffused extravasation of 
venous blood through the cellular tissue of the integument often follows such 
injuries, giving rise to a dark discoloration, which may extend to the scrotum. 
Little treatment is required in a case of this nature. Cold applications may 
be used at first, and after eight or ten hours a lotion of dilute alcohol or 
of tincture of arnica will meet every indication. 
Shot wounds affecting only the integument of the penis, independent of 
its body, rarely produce any special inconvenience; such injuries are followed, 
as in shot wounds elsewhere, by the separation of a layer of disorganized 
tissue before closure by granulation can occur; and hence the employment 
of sutures is useless, the water dressing alone being required. If, after the 
lesion, the integument becomes red, swollen, and indurated, swathing the 
organ with lint or old linen saturated with water, and surrounded with oiled 
silk or waxed paper, will prove of great value; or flaxseed-poultices can be 
substituted with equal advantage. 
Diseases of the Integument.-These are situated chiefly over the prepuce. 
Those having an inflammatory origin are oedema, balanitis, herpes, eczema, 
and hypertrophy. 
(Edema of the prepuce, in consequence of the extreme distensibility of the 
structure, is almost invariably the sequel of operations on this part of the 
penis; but in infants more commonly than in adults there exists an idiopathic, 
sometimes almost transparent, collection of serum in the lower semi-circum- 
ference of the prepuce, to which part the fluid naturally gravitates. This INJURIES AND DISEASES OF THE PENIS. 
425 
swelling is frequently induced by irritation arising from the preternatural 
length of the foreskin, from the friction of diapers, and occasionally from 
the scalding effects of the urine. The disease quickly yields to a lotion of 
lead-water and laudanum, and it is scarcely ever necessary to puncture the 
swelling in order to get rid of the serum. 
Posthitis, when not originating from a specific cause, such as gonorrhoea, is 
due to the decomposition of the smegma which collects between the glans 
penis and the prepuce. The inflammation is limited for the most part to the 
mucous surface of the foreskin, which, in adults especially, becomes abraded 
and moist, in consequence of the rapid desquamation of its epithelial cover- 
ing. The disease may commence as a balanitis, and extend to the prepuce. It 
may also be caused by the part rubbing against rough portions of the clothing, 
and by contact during coitus with irritating vaginal discharges other than 
those of a gonorrhoeal nature. 
The treatment consists in removing, as far as it is ascertainable, the pro- 
voking cause. When, as is usually the case, this cause is inattention to per- 
sonal cleanliness, frequent ablutions with warm water may be practiced, 
injecting the fluid beneath the prepuce, if the latter cannot be retracted, until 
all the caseous matter has been discharged. When occasioned by rude con- 
tact with the clothing, in addition to bathing the parts with hot water, the use 
of benzoated oxide of zinc ointment will be found to remedy the evil quickly. 
Should the inflammation have been provoked by vaginal discharges, the 
addition of a few grains of acetate of lead to the ointment will hasten the 
cure. In cases where the disease shows a tendency to relapse, I have found 
a powder of calomel and subnitrate of bismuth (equal parts) to be very effi- 
cient. Lotions or injections of alum and of borax may also be employed. 
Should the inflammation, in defiance of these measures, prove unmanageable 
and the prepuce be redundant, the only resource is circumcision. 
Preputial concretions.-Preputial irritation may be caused by the presence 
of concretions which are formed by depositions from the urine and composed 
for the most part of uric acid. There may be a single one or many such 
stones imprisoned beneath a tight foreskin. Their presence may be recog- 
nized by the solid character of the and the remedy is incision 
or circumcision, not only admitting of the ready removal of the foreign 
bodies, but also preventing them from reforming, by establishing a free outlet 
for the urine. 
There is a variety of inflammation of the prepuce which I have met with 
that is secondary to urethritis, and that is peculiarly distressing, the swelling 
extending in some instances much beyond the limits of the foreskin,-in- 
deed, even to the entire organ. The irritation and pain are always greatly 
aggravated by urination. The inflammation of the urethra, on which the 
disease depends, may be the result of a previous gonorrhoea, or may be 
caused by mechanical injury, as the impaction of a fragment of stone in 
the canal. The urethral inflammation must be combated by mild astringent 
injections of nitrate of silver or sulphate of zinc, assisted by warm fomen- 
tations of the penis with laudanum and water. 
In one case of this disease which I had under my care the suffering was so- 
aggravated by the passage of the water that the benefit obtained from local 
treatment in the intervals of urination was altogether lost. The soft catheter, 
under the circumstances, I believed would be a lesser evil than the water; 
and the result proved the correctness of this opinion, as no improvement 
took place until the adoption of the expedient of drawing the water with 
that instrument at stated periods. 
If the patient is harassed during the night with a desire to rise and empty 
the bladder, the use of a suppository of opium will become necessary for 
the purpose of allaying vesical irritation and procuring rest. 
Herpes appears as a crop of white vesicles surmounting a red base, and 
located near the junction of the skin and mucous membrane of the prepuce. 
After the vesicles open there is left a cluster of itchy, superficial sores. Per- 426 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
sons of light complexion and delicate, fair skins are the most common sub- 
jects of the disease. The vesicles occur in groups, and are prone to recur. 
Their crusts frequently cover shallow ulcerations, and require to be carefully 
removed in order to disclose the true character of the affection. 
When not arising from gonorrhoeal or syphilitic causes, herpes will often be 
found to depend on some derangement of the intestinal secretions. A cathar- 
tic, preceded by a few grains of blue mass or of calomel, will often suffice 
for the removal of the eruption. The best local application, after bathing 
the parts with warm water, is a layer of calomel dusted over the vesicles, or 
an ointment consisting of calomel, acetate of lead, and benzoated lard (calomel 
grains x, acetate of lead grains iii, benzoated lard 5ii)- 
Eczema is more diffused than herpes, the redness, heat, swelling, and irrita- 
tion extending beyond the limits of the foreskin. The inflamed surface is 
covered with minute vesicles, which, on opening, leave the skin at first moist 
and afterwards covered with crusts or scales. The disease is rarely seen on 
the penis unless at the same time occupying other parts of the body. When 
not dependent on a contracted prepuce it is quite amenable to ablutions 
associated with a lotion of lead-water, or to the use of a wash of black-wrash 
and tar-water. 
Hypertrophy of the inferior semi-circumference of the prepuce is a frequent 
sequel to chancre, and may also become a permanent condition after the 
operation of slitting up the foreskin in cases of phimosis where the integu- 
ment is redundant. The enlargement is the result of an inflammatory infil- 
tration, which subsequently becomes organized into connective tissue. When 
the hypertrophy is sufficiently important, from its bulk, to demand attention, 
the most expeditious and thorough remedy is to remove an elliptical portion 
of the growth with the knife, and afterwards unite the edges of the wound 
by the interrupted suture. During the healing the penis should be turned up 
against the pubes and so retained, to prevent the gravitation of inflammatory 
products to this part of the foreskin. 
There is a general hypertrophy of the integument of the penis which par- 
takes of the nature of elephantiasis. Mr. Bryant mentions a case of this 
kind, which, though giving a monstrous appearance to the organ, seems to 
have been regarded by its owner as a rare possession, he having declined to 
have anything done for its removal. 
To reduce a hypertrophy of this nature the organ should be surrounded 
with a roller bandage applied daily with increasing firm- 
ness, and kept under constant water irrigation. In ele- 
phantiasis of the scrotum the penis participates in the 
hypertrophy. 
Phimosis (from the Greek yt/zow, "I bind") is a term used 
to express a preternatural elongation of the prepuce, with 
a contraction of its orifice to a degree rendering it difficult, 
and in many instances impossible, to uncover the glans 
penis. (Fig. 1240.) 
This defect of the foreskin may be either congenital or 
acquired, the latter much oftener than is generally sup- 
posed. In the congenital variety the obstacle to the re- 
traction of the prepuce is entirely confined to the mucous 
membrane, which is always found closely embracing the 
head of the penis, and is thickened, short, and unyielding from its junction 
with the skin backward. 
Phimosis is frequently hereditary. I have operated on three children in 
one family all of whom were born with contracted foreskins. The evils 
which this imperfection occasions are numerous. Not only does it impose a 
difficulty in preserving a proper cleanliness of the parts by retaining the 
secretions of Tyson's glands and impeding the flow of the urine, but, as a 
consequence of this, it creates an irritation the reflex influence of which may 
Fig. 1240. 
Phimosis. INJURIES AND DISEASES OF THE PENIS. 
427 
induce incontinence of urine, symptoms of stone in the bladder, paralysis of the 
lower extremities, convulsions, masturbation, priapism, etc. The contraction 
may interfere with sexual congress, or may complicate the treatment of gon- 
orrhoea. I visited, in connection with Dr. John Lodge, of this city, a child 
who had suffered for over one year with a severe eczema, extending over the 
lower part of the abdomen, over the groins, and inside the thighs, and which 
had resisted all kinds of remedies. As the little patient had a well-marked 
phimosis, I performed a circumcision, which not only relieved the congenital 
defect, but cured in a few days the cutaneous disease. Phimosis is often the 
exciting cause of epileptiform attacks, a fact to which the attention of the pro- 
fession has been called by Professor Sayre, and which was very well exempli- 
fied in a case which I saw in consultation with Dr. Gittings, of this city. The 
patient, a child, had some days as many as eight or ten convulsions. There 
being no other detectable source of irritation to which this condition could 
be referred than that arising from a long, narrow prepuce, I advised circum- 
cision. The operation was followed by a perfect cure. Not only does this 
reflex irritability arising from phimosis involve all the voluntary muscles, as 
witnessed in general convulsions, but it occasionally selects certain groups of 
muscles, the spasmodic contraction of which may simulate club-foot, knee- 
joint disease, or even hip-joint disease. 
Treatment.-It is not every case of congenital phimosis which demands 
operative interference. Where the orifice is not so small as to interfere with 
the free escape of the urine, even though it is too narrow to allow the glans 
penis to be uncovered, it is well to wait for a few months. Remarkable 
changes frequently occur as the development of the organ progresses, which, 
by enlarging the preputial opening, may render an operation entirely un- 
necessary. 
When, however, the preputial contraction is so great as to interfere with 
the free escape of the urine, the sooner the defect is corrected the better. 
The operation may be done at any period of life from two months upward, 
the most important condition being always that the child shall be free from 
disease at the time of its performance, except such as may be the result of 
the phimosis. 
Operation.-There are three operations which answer every purpose for 
the cure of phimosis,-dilatation, circumcision, and incision. 
Dilatation.-When there is no excess of foreskin and the preputial open- 
ing is not extremely small, gradual dilatation will overcome the phimosis 
very satisfactorily. 
The instrument by which this is accomplished resembles a pair of forceps 
(Fig. 1241), the articulation being only half an inch from the end of the 
blades. 
The latter are to be introduced, closed, through the opening in the foreskin, 
and the dilatation, which at first 
must be moderate, is maintained by 
pressing the handles of the for- 
ceps together until some uneasiness 
is manifested by the patient, when 
they may be fixed by the catch and 
allowed to remain in situ for twenty 
minutes. This should be repeated 
every day or two until the prepuce 
can be easily retracted behind the glans,-the work, generally, of five or six 
days. This plan is greatly preferable to forcible dilatation and rupture of the 
mucous membrane, which is not unattended with danger, particularly with 
feeble children, by causing diffuse inflammation of the integument of the penis. 
Circumcision is an old religious rite established among the Hebrews by 
Divine command, which doubtless, like many other parts of the ceremonial 
law, had a hygienic value as well as a ritual significance. The operation 
of the priest differs materially from that of the surgeon. The former, 
Fig. 1241. 
Phimosis forceps. 428 
INJURIES AND DISEASES OF THE GENITOURINARY ORGANS. 
after drawing the prepuce through a slit in a metal ring, which is used to 
protect the head of the penis from injury, cuts it off, and then tears with his 
fingers the mucous membrane, which he turns back, keeping both it and the 
skin behind the glans by a roll of lint. No ligatures or sutures are employed, 
and consequently several deaths have been known to occur from hemorrhage. 
Circumcision is always to be preferred when there is much redundancy of the 
prepuce. As the mucous membrane is frequently found adherent to the glans 
penis,-a condition which seems to be normal in the early months of intra- 
uterine life,-the two should be separated, as a preliminary measure, by 
introducing a probe or director through the preputial opening and passing 
it round the head of the organ as far back as the corona glandis. The fore- 
skin should now be drawn forward, so that the portion which before lay over 
the middle of the glans penis shall be brought to its extremity, immediately 
in front of the latter. A pair of forceps with curved blades, the convexity 
being forward, is made to embrace firmly the foreskin. The blades being 
now fixed with the slide 
belonging to the instru- 
ment, the operator, after 
consigning the forceps 
to an assistant, seizes 
the free portion of the 
foreskin between his 
fingers and shaves it off 
with a sharp bistoury, 
close along the anterior 
surface of the forceps. 
(Fig. 1242.) The blades 
of the instrument being 
now disengaged from 
the stump of the pre- 
puce, the lattei- is to be 
drawn back, which ex- 
poses the mucous mem- 
brane still covering the 
head of the penis like a 
hood. This is now to 
be dragged forward and cut off transversely, like the foreskin, or to be slit up 
with a pair of scissors over the upper surface of the glans almost to the corona. 
If there are any adhesions between the membrane and the head of the organ 
which have escaped the probe, they may now be broken up, after which 
the flaps of the mucous membrane should be rounded off with the scissors, 
taking care not to trench on the fraenum, and their edges stitched to the in- 
tegument in four or five places with the interrupted sutures, the first one 
being always placed at the upper angle of the incision through the mucous 
membrane. (Fig. 1243.) These sutures should 
be cut leaving long ends, so that they can be 
readily discovered when the time comes for their 
removal. Any vessel which continues to bleed 
should invariably be tied with a fine ligature, as 
the sutures, however placed, will not always con- 
trol the hemorrhage, and the blood getting in be- 
tween the mucous membrane and the skin, and 
even into the connective tissue beneath the latter, 
not only interferes with the healing, but may be 
followed by fatal prostration. A linen rag wet 
with cold water must be laid over the parts, 
and kept in place in the case of children (after turning the penis up, to 
prevent swelling around the fraenum) by applying the " square" or diaper. 
The dressing will require to be renewed every three or four hours, or as 
Fig. 1242. 
Prepuce embraced with the forceps preparatory to cutting off. 
Fig. 1243. 
Mucous membrane slit up and one 
side reflected and stitched to the skin of 
the prepuce. INJURIES AND DISEASES OF THE PENIS. 
429 
often as it becomes dry. On the third or fourth day the stitches should be 
removed, and the watei' dressing continued for four or five days longer, 
aftei' which the parts may be covered with a fine, soft piece of linen spread 
with benzoated oxide of zinc ointment. 
Incision.-In cases of phimosis where there is little redundancy of the 
foreskin, incision will answer every purpose. The director being introduced, 
as in circumcision, between the glans penis and the mucous membrane, and 
any existing adhesions broken up, the operator introduces the probe-pointed 
blades of a pair of scissors between the prepuce and the glans penis, and slits 
up the foreskin over the dorsum as far as the corona. This incision is some- 
times made by first introducing a director, along the groove of which a sharp- 
pointed bistoury is passed, and, after piercing the integument ovei' the corona, 
cutting directly from behind forward. After noticing that no adhesions re- 
main between the head of the penis and the mucous membrane, the latter 
should be stitched to the skin by fine sutures, the first being inserted at the 
upper angle of the wound, and two on each side 
of the longitudinal incision. (Fig. 1244.) 
The subsequent dressing should be the same 
in all details as after circumcision. Some sur- 
geons prefer to round off the margins of the 
lateral flaps before introducing the stitches, so 
as to get rid of what they fancifully call the 
dog-eared appearance of the prepuce, which re- 
sults from a simple longitudinal incision; but 
this is unnecessary, as nature will in time do 
the same thing perfectly. There are several 
other methods of operating for phimosis, as by 
dressing forceps or dilators introduced through 
the preputial orifice, and then rupturing the 
contracted mucous membrane either by forcible 
dilatation or by sudden withdrawal of the widely-expanded blades of the in- 
strument. These operations, recommended by Hutton and by Cruise, are not 
adapted to all cases, and in some utterly fail by reason of the inflammation 
which follows the rude tearing of the mucous membrane. 
Dr. Levis has devised a forceps (Fig. 1245) the blades of which, when 
Fig. 1244. 
Operation by incision. Skin and 
mucous membrane slit up and united by 
the interrupted suture. 
Fig. 1245. 
Levis's forceps for removing the contracted mucous membrane in phimosis. 
closed, resemble the threads of a screw, and can be separated or opened at 
pleasure by a screw placed near the articulation of the blades. 
The object of the operator is to remove the contracted or unyielding 
mucous membrane without cutting away the skin, which is always sufficiently 
elastic and not at fault in phimosis. The blades are introduced closed into 
the opening of the prepuce, and then expanded by the screw at the upper 
end of the instrument. When traction is made, the sharp thread on the 
blades clings to the mucous membrane, and admits of its being drawn out 
and incised. 
In children of hemorrhagic tendencies, no operation except that of gradual 
dilatation should be undertaken. 
Acquired Phimosis arises from inflammatory thickening of the preputial 430 
INJURIES AND DISEASES OF THE GENITO-URINARF ORGANS. 
orifice, occasioned by gonorrhea, chancre, or any cause which keeps up irri- 
tation of either the foreskin or the glans penis. 
Treatment.-Frequently, phimosis originating in the above causes disap- 
pears spontaneously without any operation, the plastic deposits becoming 
absorbed after the subsidence of the inflammation. In acute cases our reme- 
dies should be addressed to the parts with a view to secure such a termination 
by removing the cause. Injections can be made either of warm water, for 
the purpose of dislodging glandular secretions, or of medicated liquids, when 
gonorrhoea or venereal sores are present. No operation should be done 
during an acute inflammatory attack, as the patient would be exposed to 
risks of erysipelas, ulceration, and sloughing. 
In most instances of acquired phimosis the operation by dorsal incision is 
all that is required, stitching together the edges of the skin and mucous 
membrane, as in the operation for congenital phimosis. When there is a 
great thickening, as is often the case, at the lower semi-circumference of the 
prepuce, from the effects of old venereal sores, circumcision will yield the 
most satisfactory results. Occasionally it happens that a concealed chancre 
exists, which cannot be successfully treated until it is fairly exposed: under 
these circumstances an operation becomes imperative. If the syphilitic sore 
is a chancroid, the wound is liable to become inoculated. To prevent this 
occurrence, Dr. Lowman, of New York, is in the habit of injecting beneath 
the foreskin and the head of the penis a forty-grain solution of nitrate of 
silver before operating, neutralizing the effects of the caustic afterwards by 
a second injection of a solution of common salt. The prepuce is then slit 
open and the edges of the incision cauterized with nitric acid. This practice, 
omitting only the salt injection, has long been in use in Philadelphia. 
Paraphimosis (~a/w., "amiss," and <pt[i6w, "I bind") is the condition which 
results from the retraction of a preternaturally narrow foreskin behind the 
corona glandis, and is, consequently, the opposite of phimosis. The contrac- 
tion which follows the new position of the preputial orifice causes a deep 
groove behind the head of the penis, which, in consequence of the rapid swell- 
ing, is lodged between the two swollen collars of the foreskin. (Fig. 1246.) 
If not soon relieved, the contraction occasions much swelling and uneasi- 
ness, with pain and inflammation, in the strangulated glans, and has in some 
instances been followed by mortification of the head of 
the organ. 
Paraphimosis is generally met with among boys or 
young men, who are not aware of the inconveniences 
resulting from an abnormally narrow prepuce. The 
habit so often indulged in by lads of slipping a ring 
or tying a string around the penis should not be for- 
gotten by the operator, as the appearance of the organ 
in cases of constriction produced in this manner is not 
unlike that which it presents in paraphimosis from 
natural causes. 
Treatment.-The reduction of the foreskin in para- 
phimosis may be effected by manual pressure conjoined 
with traction, and by incision. 
There are two methods usually practiced for reduc- 
tion by the former plan, neither of which, however, exactly fulfills the requi- 
sitions necessary to command success. These are, first, to press the blood 
out of the engorged gland; secondly, to roll the prepuce forward over the 
head of the penis. In the methods in common practice (one of which is 
represented in Fig. 1247), either the locked index and middle fingers of both 
hands embrace the penis behind the constriction, while the two thumbs are 
placed against the glans penis, or the organ is encircled by the index finger 
and thumb of one hand, while the glans penis is pressed with the index 
finger and thumb of the other. 
Fig. 1246. 
Paraphimosis. INJURIES AND DISEASES OF THE PENIS. 
431 
By either method the forces of the two hands tend to neutralize each other ; 
for the more strongly the head is pressed upon to empty its vessels and force 
Fig. 1247. 
Fig. 1248. 
Phillips's method of reducing a paraphimosis. 
Author's method of reducing paraphimosis. 
it back, the more tightly must the body of the organ be compressed to resist, 
and of course to prevent the reflux of blood, thus adding a stricture to 
the one already existing. A more rational plan is, after etherizing the 
patient, to grasp the head of the penis in the palm of the hand and compress 
it strongly for some time (Fig. 1248), until the cells of its spongy tissue are 
measurably emptied, when the prepuce can be rolled forward, and the reduc- 
tion effected with the same hand, assisted, if necessary, with the fingers of 
the other, pressing the partially flaccid glans back. 
As adjuvants to manual reduction, the local ap- 
plication of ice, punctures, and acupressure by elastic 
bands are sometimes employed. But, as a rule, if 
the surgeon fails to effect the reposition of the fore- 
skin, it is best to proceed at once to the operation. 
This consists in insinuating beneath the stricture 
the point of a curved, sharp-pointed bistoury, with 
its back towards the dorsum of the organ, while the 
glans penis is depressed between the thumb and the 
index finger, and dividing freely the constricting 
band from behind forward (Fig. 1249), when the 
prepuce can be replaced over the head of the penis 
without difficulty. 
The seat of the stricture must always be sought 
for behind the first collar of the swollen foreskin. 
To prevent a recurrence of the accident, the opera- 
tion for phimosis should be advised after the parts 
have returned to their natural condition. The only 
dressing required after the division of the stricture is one of water containing 
a few drops of laudanum. 
Fig. 1249. 
Dividing the stricture in paraphi- 
mosis. 
Short Fraenum Praeputii.-Occasionally we meet with cases in which the 
fraenum is preternaturally short, so that during erection the band is severely 
and painfully stretched, and may, in addition to causing some degree of in- 
curvation of the organ, also become fissured or torn. When the latter 
occurs, the accident is often followed by severe hemorrhage, and may leave 
a troublesome ulcer, which opens at every act of coitus. The remedy con- 432 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
sists in detaching the fraenum from the under surface of the glans, sliding it 
back, and retaining it in its new position by one or two sutures. 
Absence of the Fraenum.-The evil of a short fraenum is scarcely greater 
than that of the condition in which the bridle has been destroyed by a 
chancre and the foreskin is allowed an unlimited retraction. Persons who 
have suffered in this, manner complain of a peculiar distress, and also of an 
annoying sense of incapacity for satisfactorily executing the sexual act. 
There is reason to believe that the inconvenience and disqualification com- 
plained of are not altogether imaginary. Operations about the sexual 
organs call into the highest requisition the aesthetics of surgery; and hence, 
whether the effects of the condition under consideration are imaginary or 
not, it is proper to repair the defect as far as possible. This is to be attempted 
by freshening the centre of the foreskin on the under surface of the organ, 
and also that part of the penis which answers to the natural position of the 
fraenum, and uniting the two by two fine stitches, one on either side, or by 
one very delicate pin and thread, counteracting erections by the use of cold, 
bromide of potassium, and suppositories of opium and camphor. 
Epithelioma of the Prepuce occurs generally in old persons, or at least in 
those who have passed middle life. It commences as a tubercle, crack, or 
wart, and slowly extends its area of infiltration to the surrounding structures. 
An ulcer soon forms, which after a time throws out 
a cauliflower growth of granulations, from which 
flows a thin sanious discharge, highly offensive, and 
which irritates the adjoining parts with which it 
comes in contact. (Fig- 1250.) The disease grad- 
ually extends, destroying by small installments the 
glans penis, the prepuce, and the body of the organ, 
and involving finally the lymphatic glands of the 
groin. The disease is rarely of rapid progress, some- 
times lasting six or eight years, but finally wearing 
the patient out by pain, blood-poisoning, and con- 
stitutional exhaustion. 
Phimosis is thought by some writers to be actively 
concerned in the production of carcinoma of the 
penis. The data for such a conclusion are very 
meagre. I have seen many cases of the disease in 
which there was no previous history of any such 
condition of the foreskin. The supposed partial 
exemption from this disease of the Hebrews, who 
still maintain the rite of circumcision, has been adduced by Travers in sup- 
port of this opinion ; but I am not aware that any comparisons have been 
drawn between the numerical strength of the Jews and that of all other 
persons which would render such a supposition probable. 
Scirrhus is rarely seen in the penis, and, when present, commences, it is 
said, behind the corona glandis, most probably in the glands of Tyson, 
situated in this locality. I have never seen an instance of the disease. 
Treatment.-When epithelial disease begins on the prepuce, and is easily 
recognized, it may suffice to remove the foreskin, observing to extend the 
incision sufficiently far into the sound skin to include (so far as can be deter- 
mined) all the diseased tissue. If, however, as is usually the case, the affec- 
tion has existed for a considerable length of time, and particularly when the 
ulceration involves the glans penis, no operation short of amputation will be 
of any value. In this operation the principal part of the organ should be 
sacrificed, even though the disease may not have extended farther than the 
glans or corona of the penis. 
Amputation of the penis is a simple operation, and can be performed either 
with the knife or with the ecraseur. If the knife is employed, the circulation 
Fig. 1250. 
Epithelioma of the prepuce. INJURIES AND DISEASES OF THE PENIS. 
433 
can be controlled during the operation by an assistant grasping the organ 
above and below, close to the pubes, between the thumb and index finger, or 
by surrounding it with a narrow cord of rubber; or, finally, by an instru- 
ment (Fig. 1251) the curved blades of which can be screwed together with 
Fig. 1251. 
Clamp forceps for compressing the penis in amputation. 
sufficient force to compress the vessels. The hemorrhage, however, is rarely 
very profuse, being a free oozing rather than an arterial jet. After providing 
by one of the above measures for the bleeding, the operator, covering the 
ulcerated portion by a strip of bandage, grasps the penis with one hand, at the 
same time drawing the integument a little forward with the other hand, when 
the organ is severed by a single stroke of the knife. When the amputation is 
done near to the pubes, the stump is liable to retract, and may become buried 
beneath the pubes; though, by a little manipulation, it can usually be made 
to protrude. Yet, that there may be no embarrassment, a strong ligature 
may be passed by a needle through the fibrous sheaths of the cavernous 
bodies and tied in a loose loop, which will place the stump under perfect com- 
mand. The vessels which may require a thread are the dorsal, the two 
cavernous arteries, and the artery of the pectiniform septum. Several sug- 
gestions have been made with reference to covering the stump and preventing 
the contraction of the orifice of the urethra. The tendency of the latter to 
become so narrow as seriously to obstruct the escape of the urine is a matter 
of common observation. 
To resist this, Mr. Hilton, instead of cutting the cavernous and spongy 
bodies on the same level, divides the latter a little in advance of the former, 
afterwards slitting up the urethra and suturing its sides to the integument. 
This is a very satisfactory operation, though it is vain to expect that the 
flaps will long remain in the position in which they are stitched. 
After the amputation the parts require to be covered with lint or two or 
three thicknesses of old linen, and kept wet with cold water, or they maybe 
dressed with a piece of linen moistened with carbolic acid and sweet oil. The 
utmost attention to cleanliness must be rigidly enforced, in order that the 
discharge from the wound shall not be allowed to remain in contact with the 
spongy structure of the cavernous and spongy bodies,-surfaces admirably 
adapted to receive and transmit to the general system any poisonous products 
which might result from decomposing matters. A solution of permanganate 
of potash thrown into the recesses of the stump with a syringe will be found 
to fulfill every indication. 
To prevent the urine from running over the wound, a short, straight, 
metallic tube, or a female catheter, can be introduced into the bladder, corked 
and secured in the ordinary manner, and be allowed to remain for two or 
three days. It should then be removed, cleansed, and, if causing no irrita- 
tion, be replaced. I have sometimes, instead of carrying the instrument into 
the bladder, confined it in the urethra alone; and, although some urine may 
pass round the catheter, the largest amount will be discharged through its 
canal. 
In the course of seven or eight days, when the parts about the stump begin 
to become fixed and the raw surface commences to granulate, the instrument 
may be laid aside. After recovery, the patient must be furnished with a 
bougie and instructed in its use, so that he can at intervals of three or four 
vol. ii.-28 434 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
days, by inserting the instrument a little distance into the urethra, prevent 
any serious contraction of the orifice. In no other way is it practicable to 
surmount this difficulty. As it is impossible, after the amputation of the 
organ, for the person to project the stream of urine any distance from the 
opening, it is liable to bespatter the clothing and fall at the feet. To provide 
for this disability, a little metallic or rubber tube (Fig. 1252) can 
be used, which, fitting over the parts, will receive the flow and 
conduct it away from the person. 
If the ecraseur is employed for the amputation, the skin 
should be drawn forward some distance before the chain of the 
instrument is tightened, after which the screw may be rapidly 
turned and the organ crushed off in the space of a minute. Or 
it may be done with more deliberation, occupying for the pur- 
pose a period of ten or fifteen minutes. It is a matter of in- 
difference which plan is pursued, as the bleeding will be about 
the same in both cases. The most bloodless operation is that 
by the galvano-cautery, which is the one preferred by some sur- 
geons. 
There are cases of cancer of the penis in which the dis- 
ease has extended far up towards the pubes, and where, in 
order to get rid of a foul, offensive sore and to palliate for a 
time the severity of the pain, the surgeon will be justified in removing the 
organ, even up to the crura. In such a case it is necessary, after the removal 
of the hair, to place the patient in the lithotomy posture and with the limbs 
widely separated. Two curvilinear incisions are then made, beginning at the 
middle line over the front of the pubes, passing down one on each side of the 
penis, and terminating one inch below the peno-scrotai juncture. By dissect- 
ing these flaps of integument back a little distance the corpora cavernosa and 
corpus spongiosum will be brought into view. A long acupressure-pin being 
now passed through the former from side to side, so as to prevent retraction, 
the organ can be severed immediately in front, after which the vessels are to be 
secured. In order to open as free a passage as possible for the urine, a grooved 
staff is next introduced into the urethra and carried into the bladder, when 
the operator makes a free incision through the raphe of the perineum, dis- 
secting down until the bulb of the corpus spongiosum is reached. One inch 
forward, separate the latter from the cavernous bodies, and, after slitting 
up the urethra longitudinally, stitch it to the sides and the anterior angle 
of the perineal wound. This will secure an uninterrupted outlet for the 
urine. If there is no bleeding, the long acupressure-pin commanding the 
cavernous bodies should now be removed, a small drainage-tube introduced, 
the anterioi* wound closed over the stump, and the staff removed from the 
bladder. 
Even when the inguinal glands are enlarged, and where nothing more than 
palliation can be promised, so great is the comfort experienced by a patient 
in being temporarily freed from an offensive disease like the one under con- 
sideration, that I do not hesitate to advise an operation. The prepuce 
may occasionally be the seat of benign growths, as sebaceous, vascular, 
fibrous, and adipose tumors, which are amenable to the same plans of treat- 
ment as would be adapted to similar tumors situated in other parts of the 
body. 
Inflammation of the Penis may arise directly from injury, or indirectly from 
the extension of an irritation from a virulent ulcer, as a phagedenic chancre 
or a severe urethritis. In whatever manner it originates, there is great 
heat, with swelling, induration, and pain of the organ, the suffering being 
much aggravated by erections. 
When the patient is vigorous and not reduced from the effects of a slough- 
ing chancre, a few leeches applied along the course of the dorsal artery of the 
penis will afford marked relief. The organ must be swathed with hot anodyne 
Fig. 1252. 
Urinal for use 
after amputa- 
tion of the pe- 
nis. INJURIES AND DISEASES OF THE PENIS. 
435 
fomentations, and the erections controlled by the free use of bromide of potas- 
sium and suppositories of camphor, opium, and lupulin. As the passage of the 
urine often increases the suffering, it must be rendered as bland as possible 
by giving freely alkaline diluents. There is a chronic form of inflammation 
which may commence as such, or may succeed an acute attack, and which is 
very local or circumscribed in extent, occupying some part of the cavernous 
body. The transudation filling the cells of the erectile tissue destroys the 
extensibility of that portion of the corpus cavernosum involved, while the 
other remains unimpaired, and necessarily, in the turgid condition, turns the 
organ towards the diseased side. These inflammatory deposits may extend, 
or they may disappear at one point and appear at another. When arising 
from syphilitic causes (which I am confident is sometimes the case), the dis- 
ease is amenable to large doses of iodide of potassium and tonics, under the 
influence of which remedies the erectibility of the organ, when lost, may be 
restored. When no syphilitic history can be made out, iodide of iron and 
cod-liver oil are worthy of a prolonged trial. 
Gangrene of the penis may attack either the integument or the organ itself. 
It may have an inflammatory or an obstructive origin. As a result of the 
former, it is occasionally seen accompanying destructive ulcerations, such as 
sloughing chancre, or after operations for phimosis in children of irritable 
constitution. When limited to the integument the inflammation presents 
the character of erysipelas. It is announced by great swelling, tenderness, 
and a dusky-red color of the skin, and, if not arrested, is soon followed by 
a dark-lead or purple discoloration, quickly changing to black. The general 
system sympathizes with the local disorder. The pulse becomes frequent and 
feeble, the tongue dry and covered with a brown coat, and there are headache, 
loss of appetite, and exhaustion. To prevent, or at least to limit, the sloughing, 
it is important to unload the cellular tissue of the integument of its infiltra- 
tion, by making early two or three incisions into its structure, as is usually 
practiced in phlegmonous erysipelas. After this is done, the ordinary hot- 
water dressing or flaxseed poultices will constitute the best local application. 
The general system must be supported by nourishment, stimulants, and tonics, 
and nervous restlessness is to be allayed by anodynes. 
The obstructive variety of gangrene which is met with in the penis may arise 
from either a mechanical or a pathological cause. 
Mechanical causes.-Boys have a mischievous habit of slipping rings over 
the organ, or surrounding it with a cord, while in a flaccid state. During 
erection the irritation caused by the compression provokes an inflammatory 
swelling, during which the constricting body becomes buried in the tissues 
and passes more and more out of sight, until the vitality of the distal part 
is either lost or seriously imperiled. Many curious cases of this nature have 
been recorded. A boy among the out-patients of St. Bartholomew's Hos- 
pital complained of having lost all sensation in the penis, and had, in addi- 
tion, a urinary fistula. The organ was threatened with mortification. On 
examination there was found deeply buried in the organ a string, which some 
time previously had been tied around its base, and which had gradually cut 
its way through the parts. All the nerves and vessels had been severed.* 
In another case,-a man, fifty years old, who was brought before the Medical 
Society of the Hospital of Paris,-seven iron rings were found over the 
penis towards the pubes. Gangrene was impending in this case, when the 
rings were cut away and the penis saved.f Guillot relates a case in which 
a gold wedding-ring was used in the same manner. A case is also told 
of a wet-nurse who wound a long hair from her head five times round the 
root of the penis of a Jewish boy four weeks old, and each time tied on it a 
firm knot. The cause of the child's suffering was with difficulty ascertained, 
and the constriction removed in time to prevent mortification.£ The con- 
* Half-Yearly Abstract of Medical Sciences, vol. xxv. p. 180. 
f Lancet, April 4, 1868, p. 440. 
j Dublin Medical Journal, vol. i. p. 246. 436 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
striction of a tight paraphimosis may be sufficient to interrupt seriously the 
circulation in the glans penis and to endanger its life. The sign which 
indicates a strangulation of the penis from the causes above enumerated is 
the presence of a narrow sulcus at some portion of the organ. The remedy 
consists in etherizing the patient, dilating the fissure, and dividing the con- 
stricting body. When the latter is composed of metal, it will require to be 
cut with the bone pliers. 
Pathological or idiopathic gangrene, a subject which has particularly engaged 
the attention of Dumarquay, is an uncommon occurrence. My own knowl- 
edge of the disease is confined to a single case, which occurred in the surgical 
ward of the Philadelphia Hospital. The patient was an aged man, and one 
whose constitution had been seriously shattered. The discoloration com- 
menced without known cause, and was at first characterized by deep purple 
lines, answering to the branches of the great dorsal vein; this was gradu- 
ally followed by discoloration of the integument, and later by a similar con- 
dition, with ulceration, of the glans penis, gradually, but slowly, creeping 
upward, until a large portion of the organ was destroyed, and eventually the 
patient succumbed. The cause of the sloughing in this case was embolism 
of the dorsal artery. The disease has been observed to follow typhoid fever 
and other exhausting affections; and, as we not unfrequently witness ob- 
struction of the veins of the legs and mortification of the feet from blood- 
changes incident to the former disease, it is to be presumed that the true 
cause of the gangrene under consideration consists in phlebitis and embolism. 
Where the vessels are thus occluded, treatment can be of little avail, and the 
efforts of the surgeon must be directed to deodorizing and disinfecting the 
parts by antiseptic washes, controlling hemorrhage, should it occur, by the 
persulphate of iron, and sustaining the strength with nourishment, stimulants, 
and tonics. 
Fracture of the Penis.-This term is used to designate an injury which 
consists in a laceration of the dense fibrous cylinders which inclose the spongy 
tissue of the corpora cavernosa. The laceration can occur only when the 
organ is in a state of extreme erection. While in this condition, it has 
been broken by being suddenly and forcibly bent, either accidentally in coition 
or maliciously by the hand of another. The laceration is known by a sense 
of something having been broken, intense pain, and a sudden subsidence of 
the tumescence of the organ, accompanied by nausea, and for a short time by 
general prostration. In one case communicated to me, the injury occurred 
by the patient's suddenly rising from bed and falling against the bed-post 
while the penis was in a state of priapism. The rupture is followed by a 
large extravasation of blood into the spongy tissue of the corpora cavernosa 
and great swelling of the penis, which may even extend to the scrotum. If 
the injury is confined to one of the cavernous bodies, the organ will be turned 
somewhat towards the side opposite that injured. The sanguineous ex- 
travasation will be followed by inflammation and the transudation of lymph, 
which, becoming incorporated with the blood, forms a hard mass. Most of 
this will in time become absorbed, though usually there remains an indura- 
tion, which, being altogether unlike the spongy tissue in the midst of which 
it lies, gives rise to a lateral or upward curvature in erection, according as 
one or both cavernous bodies have participated in the accident. This con- 
dition seriously interferes with the sexual act. In some instances the organ 
is permanently rendered hors du combat. Even death has been known to 
follow this injury, in consequence of blood-poisoning. 
The treatment must be directed towards averting the internal extravasation 
of blood, combating inflammation, and securing the absorption of inflam- 
matory and other products. The first two objects are best attained by 
surrounding the penis with cloths soaked in ice-water, and by compression 
with strips of muslin; and the third by stimulating friction, and especially by 
well-graduated pressure. If the hemorrhage is so profuse as to endanger INJURIES AND DISEASES OF THE PENIS. 
437 
the vitality of the organ and induce mortification, an incision should be 
made into the spongy tissue, and the blood allowed to escape. During the 
cure, something may be done to prevent subsequent distortion by encircling 
the organ with a plaster roller, which, after the bandage becomes hard, must 
be slit up along the dorsum of the penis, and can be slipped off and on over 
the dressing at pleasure. In this way the part may be kept in a straight 
position. 
Curvature of the Penis.-In cases less severe than those just enumerated, 
the injury may amount only to a limited extravasation of blood into the erectile 
tissue of one of the corpora cavernosa, which is followed by an equally limited 
inflammation and transudation of lymph. This becomes organized into a 
dense mass of connective tissue, which renders this part of the penis inex- 
tensible. The effect of an erection is to cause a bend or angle in the organ 
towards the diseased side, which is sufficient to defeat sexual intercourse. 
The consciousness of such a disability is often sufficient to induce extreme 
despair. 
This condition may to a considerable extent be remedied by an operation 
devised by Physick, which consists in dividing the integument and retracting 
its edges sufficiently wide apart to admit of a wedge-shaped piece being ex- 
cised from the sound corpus cavernosum, directly opposite the induration, 
and closing up the wound in the same by deep interrupted sutures, over 
which the integument is to be brought together and retained by a few stitches. 
The organ requires to be supported in a leather or plaster splint, and erec- 
tions must be subdued by cold water and anodyne suppositories. The 
stitches should be allowed to remain as long as they retain their hold and do 
not become loose. 
Luxation.-The connection between the glans penis, the rounded extremity 
of the cavernous bodies, and the corpus spongiosum is such that one might 
anticipate its displacement under the application of some inordinate force. 
A preparation was at one time in my possession which appeared to verify 
the possibility of this accident; but I have reason to believe that the disloca- 
tion was the work of the knife rather than an accident. 
Nelaton has furnished an example of a backward luxation of the cavernous 
bodies from the spongy body, which was reduced by drawing the former 
forward into place. 
Calcification.-Hard, gristly masses of fibrous tissue, which in time undergo 
calcareous transformation, are occasionally observed in the structure of the 
corpora cavernosa. These may occupy any or a great part of these bodies. 
They may be felt on the pectiniform septum, and I have seen them near 
the corona. They are, so far as my observation extends, confined to persons 
beyond mature life, or at least at that age when atheromatous changes are 
common in the vascular system. The presence of these masses gives rise to 
such alterations in the form of the penis, when erect, as to interfere with or 
entirely prevent sexual intercourse. The only remedy, in cases where the 
induration is limited, is excision. 
Priapism is a morbid erection of long continuance, unattended by any 
pleasurable sensation. It is generally dependent on some irritation acting 
on the brain or spinal cord. Thus, it has been frequently witnessed after san- 
guineous extravasation in the cerebellum, fractures of the spine, and severe 
concussions of the spinal cord. In a lad who was under my care and had 
been thrown under a street-car, receiving, in addition to several fractures of 
the long bones, a fracture in the upper dorsal region, followed by paraplegia, 
priapism continued unremittingly for three months. This affection is some- 
times produced in children by a narrow prepuce, and may also follow certain 
irritations acting on the neck of the bladder, as that from cantharides. 438 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Priapism is sometimes witnessed in persons who die from strangulation, 
as in hanging. 
Treatment.-When priapism is the result of lesions in the brain or the 
cord, little can be done to relieve the patient, though it usually disappears as 
the central improvement advances. When it arises from wounds or diseases 
of the penis, it is best controlled by the local application of cold, suppositories 
of opium, camphor, and lupulin, and the free use of bromide of potassium. 
Though sexual intercourse is possible in this state of the organ, it is un- 
attended with any venereal desire, and rarely accompanied by pleasure or 
seminal ejaculation. 
Warts, though in a large majority of instances having a venereal origin, 
occasionally occur from a neglect to remove the accumulation which takes 
place beneath a tight foreskin. The seat of these growths 
is on the glans penis and around the margin of the pre- 
putial opening. (Fig. 1253.) As they thrive in a moist 
soil, it is important to apply some good absorbent and 
astringent remedy, the best being a mixture of calomel 
and gallic acid (calomel three parts, gallic acid one part), 
at the same time interposing a little lint between the 
foreskin and the glans penis. As the vitality of these 
warts is very low, they will frequently shrivel up and 
disappear under the influence of this powder. When this 
is not the ease, they may be divested of all moisture, 
and touched once every three or four days with a little 
chromic acid, and afterwards covered with absorbent 
cotton. Finally, if these means are not successful, we 
have a certain remedy in clipping them off on a level 
with the surface on which they grow, and, after cessa- 
tion of the bleeding, which is generally profuse for a 
time, touching the base of each one with a crayon of 
nitrate of silver, or with a little nitric acid. 
Fig. 1253. 
Warts on the penis. 
Wounds of the Penis may be either accidental, self-inflicted, or criminal. 
Accidental wounds of the penis are not very often seen, except as shot 
injuries, and as such they constitute comparatively a very small number. 
Only 309 cases of this class of injuries were reported during the late Amer- 
ican war, 41 of which, or 13.26 per cent., proved fatal in consequence of 
the accompanying complications. In several instances balls were extracted 
from the penis shortly after their entrance; but they may become harm- 
lessly encysted. Eve has recorded an instance of a ball lodging in the 
prostatic portion of the urethra, from which it was extracted by perineal 
section. 
Shot wounds of the penis, when they involve the urethra, constitute a 
troublesome complication, as the fistulse which form are very difficult to 
manage. 
When a shot missile passes through or lodges in the corpus cavernosum, 
it is followed by considerable extravasation of blood into the contiguous por- 
tions of the spongy tissue of the organ; but there is little external hemor- 
rhage. The separation of the slough and the repair by granulation leave a 
cicatricial hardness, which materially interferes with the distensibility of this 
portion of the organ, and in erections is followed by deformity. 
The treatment of shot wounds in the penis consists in the removal of the 
foreign body, if any is present. The dilatability of the spongy tissue of 
the organ admits of an easy exploration and extraction of the ball. The 
organ is afterwards to be kept enveloped in lint or linen rags wet with cold 
water. 
Incised wounds of the penis, though sometimes accidental occurrences, 
are more commonly the work of insanity, jealousy, or malice. Bertherand INJURIES AND DISEASES OF THE PENIS. 
439 
mentions the case of a French soldier in Algiers, whose penis and scrotum 
were bitten by a dog, and Stromeyer relates another, also of a soldier, in 
whom almost the entire integument was torn off by the teeth of a horse 
while the man was unclothed and in the act of washing his body. A not 
altogether dissimilar case is that of a patient of Mr. Hilton, admitted into 
Guy's Hospital, in whom the penis had been bitten by a stallion. 
A man was brought into the Pennsylvania Hospital with a deep, lacerated 
wound of the penis, which he confessed had been inflicted by the teeth of a 
negro during a beastly and unnatural use of the organ. Otis records two 
attempts made by insane soldiers to cut off the genital organs, in both of 
which cases severe wounds were inflicted. The same author mentions the 
case of another soldier who had the penis cut off in a broil, close to the pubes. 
Numerous instances might be adduced of these mutilations from the records 
of insane hospitals. 
Self-mutilation from motives of a religious character has been practiced 
by a small body of fanatics in Russia. These people ground the authority 
of their sect on the 12th verse of the 19th chapter of St. Matthew's Gospel. 
Singular though it may seem, the followers of this creed became sufficiently 
numerous to demand for their suppression the strong arm of governmental 
interposition. Pirogoff speaks of having examined a number of these persons 
in the prisons of Russia, in whom the genitals were removed close to the 
body. 
Treatment.-The indications in the treatment of incised injuries of the 
penis are, first, the arrest of hemorrhage; second, the approximation of the 
edges of the wound ; and, third, the control of erections. The first indication 
is often best fulfilled by carrying into effect the second,-that is to say, the 
bleeding may require nothing more for its control than pressure produced by 
bringing the sides of the wound together. Should this not be sufficient to 
staunch the flow, the vessel or vessels must be sought for in the wound and 
tied. If this is found impracticable, it will be necessary, after inserting a 
sufficient number of deep sutures, to introduce a large-sized metallic catheter 
into the bladder, and, after firmly bandaging the organ, to keep the dressing 
constantly wet with cold water. In an obstinate case of bleeding, other 
means having failed to arrest the flow, an acupressure-pin might be passed 
over the dorsal artery of the penis, immediately in front of the pubes, or the 
pin might be passed beneath the vessel and the compression applied by a 
thread passed over its end as in forming a twisted suture. 
The extent to which the penis may be divided and yet union take place is 
a question which has not been satisfactorily determined. Boyer and others 
have stated that if the corpora cavernosa be severed to the extent of two- 
thirds of their thickness reunion need not be expected, and that it will be 
better, under such circumstances, to amputate the part. Such an opinion 
requires confirmation before it should be accepted as an established surgical 
maxim. I should make an effort to secure union as long as any continuity 
of tissue remained. The great vascularity of the organ and the firm sheaths 
of the cavernous bodies, well calculated to retain sutures and preserve a due 
apposition, are conditions which render success at least possible. The sutures 
in such a case ought to be numerous. 
Wounds of the Corpus Spongiosum and Urethra have the serious disadvan- 
tage of being exposed to the contact of the urine, and, consequently, have 
a strong tendency to the formation of a urinary fistula. A catheter in such 
cases must be immediately introduced and retained in the bladder, so as to 
keep the urine from the wound, the edges of which should be neatly approxi- 
mated and retained by numerous sutures, introduced as deep as the submu- 
cous tissue of the urethra. Though the objections to retaining an instrument 
a long time in the bladder are substantially just, yet in a case of this nature 
it is the lesser evil of the two, and it should not be withdrawn for at least six 
days, or until the union of the wound is tolerably well assured. The water 440 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
dressing, containing a little laudanum, constitutes the best application in all 
wounds of this organ. One of the difficulties to be encountered in injuries 
of this nature is troublesome and frequent erection, which demands for its 
relief the local use of cold, with full doses of bromide of potassium, and 
suppositories of opium, camphor, and lupulin. 
Laceration of the Urethra.-This is by no means an uncommon accident, 
and may be produced in various ways,-by kicks, falls, or blows on the peri- 
neum ; by straining efforts to pass the urine through a tight stricture; by a 
spiculum of bone in fractures of the pelvis; and even in coition. Laceration 
may also be produced by causes acting from within, as by the impaction of 
a stone which is too large to pass through the urethral canal, and by the 
maladroit use of instruments, as the catheter or the bougie. 
The degree of laceration varies much in different cases. It may be a slit, 
a round or oval opening, involving only a small part of the circumference of 
the canal, or the urethra may be torn completely across. 
The location of the laceration may be in the penile or the perineal portions 
of the urethra. The danger of these injuries is greatest when the perineal 
portions of the tube are involved, as the complex arrangement and the con- 
tinuity of the perineal and pelvic fasciae exercise great influence on the course 
and disposition of urinary extravasation. 
But, while this is true with regard to the life-risks, it does not imply that 
the difficulty of effecting a cure is greater in this division of the urethra than 
in the penile portion. On the contrary, the converse is true. Lacerations in 
the penile portion are less amenable to treatment than those in the perineal 
division of the canal, chiefly because the latter is exempt from the disturbing 
influence of erections. 
The injury at first may be readily overlooked, but should always be sus- 
pected when succeeding a sufficient injury there are experienced pains in the 
course of the canal, hemorrhage, and a frequent desire to urinate, the effort 
to accomplish this being usually fruitless. The character of the accident 
will become more evident if, in order to relieve the vesical tenesmus, an at- 
tempt is made to introduce a catheter into the bladder. The instrument 
becomes arrested in the canal at the seat of rupture, or it passes through the 
opening and takes a direction different from that towards the bladder, im- 
parting to the fingers a peculiar sensation very unlike that produced by a 
sound urethra. 
A few hours, however, are sufficient to remove all uncertainty in regard to 
the nature of the injury. The external parts, though unbroken, begin to 
assume a dark-purple hue in consequence of the extravasation of blood, and 
on emptying the bladder, either voluntarily or spasmodically, the urine 
escapes through the laceration into the surrounding parts, and gives rise to 
increased swelling. This secretion, acting as a violent irritant to the tissues 
with which it comes in contact, sets up an intense inflammation, which, unless 
its nature is promptly recognized and the infiltration evacuated, will be fol- 
lowed by extensive suppuration and sloughing; nor is the irritation limited 
to the structures adjacent to the urethra; it extends to the general system, 
causing severe rigors, marked febrile excitement, thirst, restlessness, extreme 
prostration, and delirium. The position and limitations of the local swelling 
are determined by anatomical peculiarities of structure. When the perineal 
part of the urethra has been lacerated, the swelling and discoloration will 
be confined to the scrotum beneath the dartos muscle and to the under part 
of the penis and the lower part of the abdomen, never occurring on the inner 
side of the thigh, or around or behind the rectum, so long as the attach- 
ments of the middle perineal fascia and the fascia itself laterally and poste- 
riorly remain intact. 
Treatment.-If called immediately on the reception of a severe contusion 
leading to the supposition that the urethra may be lacerated, the surgeon 
should at once proceed to introduce a catheter into the bladder, in order to INJURIES AND DISEASES OF THE PENIS. 
441 
avoid the risks of infiltration. This instrument may be either metal or gum, 
preferably the latter, and should be of medium size. A small catheter is 
passed with much greatei* difficulty in a case of this kind, and is much more 
likely to get off the track, than a large one. A catheter of good size, by un- 
folding the plications of the urethra, tends also to prevent the urine from 
escaping between the instrument and the walls of the canal. The sooner, 
too, the attempt is made to reach the bladder, the less difficulty will be en- 
countered, as the swelling which succeeds the injury offers a serious obstruc- 
tion to the operation. 
To reach the bladder, after a laceration of the urethra, safely and quickly 
and by gentleness and address, before urination occurs, is a most important 
achievement. Though the difficulties of safely passing the laceration and 
reaching the bladder are in many instances very great and perplexing, 
every possible resource should be brought into requisition before abandoning 
the operation as impracticable. The obstacle to introducing the instrument 
is presented not only by the inflammatory swelling around the canal, but 
also by the particular direction in which the laceration runs. In longitudinal 
rents a patient and dexterous hand will generally succeed ; but in those 
which are transverse, especially if complete (entirely severing the continuity 
of the canal), the most exceptional skill may be found unequal to the task. 
The conditions in which the introduction of the catheter is useless, at least 
in the early history of laceration, are the following: first, when urinary in- 
filtration has taken place; second, when, notwithstanding the instrument 
has been placed in the bladder, the water is found to pass between its sides 
and the wall of the urethra. Under these circumstances the catheter not 
only fails to accomplish the object of its use,-that of protecting the extra- 
urethral tissues from urinary infiltration,-but, also causes additional irritation 
to the parts. 
During the presence of the cathetei* in the bladder, its extremity should 
be corked, and the urine allowed to escape at convenient intervals of one, 
two, or three hours, unless it is discovered that a certain degree of uneasi- 
ness is experienced by the patient whenever a small accumulation takes place 
in the viscus, when it will be better to leave the tube open, so that the water 
may escape as soon as it enters the bladder, and thus prevent any spasmodic 
expulsion of its contents. 
Presuming, then, that the catheter has been successfully introduced, another 
important question arises, as to the length of time which it is proper to re- 
tain the instrument in the bladder. I may say that no certain period can be 
fixed; the whole question must be determined by the tolerance of the parts 
and by the location of the laceration. When the latter is in that part of the 
urethra in front of the scrotum, I believe that after thirty-six hours, or as soon 
as the risk of involuntary or spasmodic expulsion of the urine is over, and the 
vesical irritation attending the injury has subsided so that the patient pos- 
sesses a reasonable command over the bladder, it is better not to wear a 
catheter at all. But it should be used whenevei* the necessity for evacuating 
the bladder arises, or, what is better, at such regular intervals as experience 
shows the urine can be comfortably retained. When, however, the deeper 
parts of the urethra are torn and the difficulties of introduction have been 
considerable, it is better to allow the instrument to remain five or six days 
without being withdrawn, unless it creates a degree of irritation which ren- 
ders its presence in the bladder harmful. Some, indeed, have advocated its 
retention until complete restoration of the lesion. I do not concur in the 
propriety of such a practice, however, believing that its protracted presence 
is not only inimical to cicatrization, but also tends to beget an irritable and, 
consequently, a non-retentive bladder. I have seen a catheter w7orn contin- 
uously for eight months, only being removed for the purpose of cleaning 
once every few days, and yet without success, the opening in the urethra 
refusing to heal. I directed the patient to cease wearing the instrument, 
and taught him how to introduce it himself, in order that the urine might be 442 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
drawn a certain number of times in the twenty-four hours. In three weeks 
he was well. 
Catheters, when long retained in the bladder, become encrusted with the 
salts of the urine, and from this cause give rise to vesical irritation and te- 
nesmus. A gum instrument is rendered in a few days both unfit and unsafe 
for use. The main objection to the withdrawal of the catheter, that its re- 
moval and subsequent reintroduction will probably break up any repair which 
may have begun and leave the patient again exposed to urinary infiltration, 
is not altogether without force. Yet, if the instrument becomes a source 
of uneasiness to the patient, the other horn of the dilemma is presented,- 
that of tenesmus and irritation, which may induce the same evil. The 
danger anticipated by the advocates for prolonged instrumental retention 
is not likely to follow the withdrawal, but rather the act of replacing the 
catheter. The latter operation, however, may be much simplified and made 
safer by introducing a filiform guide through the catheter before withdrawing 
the latter, and allowing it to remain as a guide over which the instrument 
can be passed. This device, well known to surgeons, I have frequently em- 
ployed with complete success, when I felt confident that without it I should 
not only have encountered difficulty, but should probably have inflicted some 
injury upon the lacerated part. 
The catheter, after its second introduction, should not be allowed to remain 
as long as in the first use of the instrument, unless its presence creates no un- 
easiness, when there can be no objection to prolonging its stay in the bladder. 
The object should be to shorten the period of its continuous use after each 
change or renewal of the instrument, until after eighteen or twenty days, 
when it should be employed only at proper intervals as a substitute for vol- 
untary urination. 
During the period of instrumental treatment, the parts should be covered 
with cold or hot fomentations, according as the sensations of the patient ap- 
prove or disapprove. The vesical irritation must be palliated by anodyne 
injections of laudanum and starch-water, or by opium suppositories. In the 
course of from fourteen to sixteen days the lesion in the wall of the urethra 
will have been repaired, when the catheter may be laid aside. At one time 
I supposed it necessary, in order to guard against any probable reopening of 
the cicatrix under the distending force of the column of water, either to draw 
the urine or to instruct the patient to do so with a soft catheter, at stated 
periods in the twenty-four hours, for one week after the wearing of the 
catheter was deemed unnecessary. But for several years I have abandoned 
the practice as useless. 
When, in consequence of the extent of laceration, the instrument can- 
not be inserted, or fails to carry away all the urine, the patient should be 
placed in the lithotomy position,with the limbs drawn up and widely sepa- 
rated. A catheter, staff, or sound should then be conducted along the 
urethra to the point of obstruction, and the soft parts freely divided from 
without inward, until the damaged part of the canal is reached and a free 
communication established between the urethra and the surface, through 
which the urine may find a ready and unembarrassed escape. If the urethra 
has been torn entirely across, an attempt should be made to bring the re- 
tracted ends together, not by stitching the tube in its whole circumference 
(this would be a fruitless task), but by introducing one or two sutures through 
the upper wall of its two extremities and drawing them together. This will 
serve to diminish the amount of cicatricial tissue necessary to fill up the gap, 
and materially aid in restoring the continuity of the canal. The stitch- 
ing can be done over a small soft catheter, which will partially expand the 
sides of the urethra. This accomplished, there is, for the time, no further 
necessity for the catheter. The water must be allowed to flow through 
the wound until the lattei' is well filled up with granulations, when the 
time has come for giving form, continuity, and capacity to the urethra. 
A metallic bougie of moderate size should be gently passed through the INJURIES AND DISEASES OF THE PENIS. 
443 
canal into the bladder, and this must be repeated every day or two, if well 
tolerated, and with graduated instruments of larger size. As soon as the 
external opening has in a good measure closed, a large catheter must be 
substituted for the bougie. In the use of the former the patient, if rea- 
sonably intelligent, can be readily instructed. With this instrument, at 
stated periods, the urine must be drawn ; the object being to divert the 
stream altogether from the abnormal route and to secure solid cicatriza- 
tion. When this has been completed, it will long remain necessary, after 
all cases of urethral laceration, for the patient himself, or his medical at- 
tendant, to introduce a bougie, to prevent an obstructive contraction of the 
canal at the seat of injury. This tendency to stricture is always much 
greater in transverse than in longitudinal lesions of the urethra. 
Too often the surgeon is not called, or the medical attendant fails to recog- 
nize the laceration, until the perineum and the scrotum have become dis- 
tended with urine and the cellular tissue infiltrated with bloody pus and in a 
sloughing condition. Two or three free incisions must be made sufficiently 
deep and long to empty the parts of the vitiated extravasations, and through 
which the dead cellular tissue can be discharged. Hot-water dressings or 
warm poultices are next to be applied. In these cases the effects of the shock 
and irritation on the general system demand attention. Tonics, stimulants, 
and anodynes, in addition to good nourishment, are now necessary to coun- 
teract exhaustion, pain, and nervous restlessness. 
Until the inflammatory swelling has subsided and the general condition of 
the patient improved, it is not necessary to introduce the catheter. The in- 
cisions are sufficient for the time to afford a way of escape for the urine. As 
soon, however, as the general and local appearances have improved, requiring 
usually five or six days, the time has arrived to divert the stream of urine 
from the incisions, in order that the urethral lesion may be repaired, when the 
catheter must be inserted. If this can be done without difficulty, it is an 
evidence that the laceration, both as regards extent and direction, is not a 
bad one. The instrument, in this case, may be allowed to remain for three 
or four days, after which, if the patient has a good control over the bladder, 
it may be removed, and only used at regular periods during the twenty-four 
hours. If, on the other hand, the catheter cannot be introduced beyond the 
seat of injury, or, when introduced, fails to conduct away all the urine, a 
part continuing to escape through the perineal incisions, then a direct com- 
munication must be made between the laceration and the perineum by a free 
cut. This cut can be guided by a catheter or a staff conducted along the 
urethra to the seat of trouble. This will allow the primary incision to heal 
up. The other details of treatment will be the same in all respects as those 
already described. 
When the urethra has been perforated from within outward, as often hap- 
pens in the careless use of catheters and bougies, urinary infiltration does not 
necessarily follow. The opening being made in a direction opposite to the 
course of the urine, the mucous membrane of the canal is forced over the 
aperture by the passage of the water, and acts as a valve to close the open- 
ing. These false passages, however, are by no means harmless, but often lay 
the foundation for urinary fistulas. When they can be detected very soon 
after they occur, the proper course is to draw the water at regular intervals 
for ten or twelve days, until the damage has been repaired. The catheter 
used for this purpose should be a soft one, and only of medium size, so as 
not to distend the urethra. 
If, after a laceration of the urethra, there follows a retention of urine, and 
it is found impossible to introduce the catheter, the proper course will be to 
lay open the perineum freely down to the seat of the lesion, guided by 
the catheter or the staff. When the vesical extremity of the torn urethra 
is reached, the instrument may be entered through the wound and the 
bladder emptied. This procedure has the advantage not only of relieving 
the retention, but also of providing against the evils of subsequent urinary 444 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
extravasation, and of placing the parts in the most favorable position for 
permanent cure. 
When the skill and courage for this operation are not immediately at com- 
mand, the urgency of the retention may be met by aspirating the bladder 
above the pubes. 
Urethral Fever. 
All operations upon the urethra, however simple, and whether the canal is 
sound or diseased, are liable to be followed by a certain amount of constitu- 
tional disturbance, which has been distinguished by the term urethral fever. 
The intensity of this disturbance of the general system varies greatly in 
different persons. It may consist only in a slight chilliness, followed by a 
moderate .increase of heat, with perhaps a little nausea and pain in the loins, 
with scarcely any acceleration of pulse, all of which passes over in an hour 
or two; or it may be ushered in with a violent and prolonged rigor, followed 
by great prostration, vomiting, headache, insatiable thirst, a high tempera- 
ture, a rapid circulation, sweating, and a diminished or even suppressed uri- 
nary secretion. The chill and other symptoms sometimes recur with a 
certain degree of periodicity, and in this respect simulate an attack of mias- 
matic fever. These phenomena may ensue immediately on the withdrawal 
of a catheter or bougie, or after the passage of the urine, or they may not 
appear for several hours after, rarely after the first day. The occurrence of 
such a train of symptoms furnishes ground for uneasiness. We are neces- 
sarily, for a time at least, left in doubt whether these rigors, fever, and sweat- 
ing may not be the result of poisoning from the introduction into the blood 
of septic or uraemic matters. Especially will there be reason to fear such 
an accident if there has been any evidence of pre-existing renal disease. 
On this account every surgeon should ascertain, as far as possible, the state 
of the kidneys, when contemplating any important operation on the urinary 
organs. The records of surgery abound with fatal cases following the treat- 
ment of stricture by instrumentation; indeed, death has followed in a number 
of instances the simple act of introducing a catheter. In most of these fatal 
cases, where an examination of the internal organs has been made, there 
were discovered granular and other degeneration of the kidneys. Dr. Dick- 
inson, in the first number of the London Lancet for March, 1873, describes a 
condition of renal pyaemia which is produced by the damming back of the 
urine, and which is characterized by emboli in the vessels of the Malpighian 
cones, and purulent accumulations in the intertubular connective tissue and 
around the walls of the veins. 
The nature of urethral fever is very imperfectly understood. The fact that 
it is often postponed, after an operation on the urinary organs, until the urine 
is first passed, would seem to imply that there had been some laceration or 
abrasion of the mucous membrane, and that the contact of the urinary secre- 
tion with this had developed the general disturbance. But there are many 
instances of such attacks following the most gentle instrumentation, where 
it is exceedingly improbable that any such injury could have existed. Still, 
we may have traumatic fever, w'hich I regard the disturbance to be, without 
any visible lesion of the structures of the canal. The contact of an instru- 
ment with the mucous membrane may, in a peculiarly susceptible condition of 
the urethral nerves, and in virtue of their connection with other portions of 
the nervous system which are concerned in secretion and circulation, call 
into activity the whole group of symptoms which belong to this disorder, 
just as any other irritant may do. 
When the fever is complicated by pyaemic symptoms, the poisoning is not 
due to anything introduced into the system from the urethra, but in all prob- 
ability is occasioned by products which originate in the urinary secretions 
and re-enter the blood, or by the failure of the renal organs to eliminate the 
results of tissue-metamorphosis. 
Suppression of urine not unfrequently follows operations on the urethra. URETHRAL FEVER. 
445 
It may occur immediately after the use of an instrument, or it may appear 
in the course of the urethral fever. When the secretion is only diminished, 
as is often the case, or is retained for a longer period than is natural, there 
is little ground for anxiety, as this circumstance is quite common after 
severe operations of any kind, the kidney, in common with all the internal 
organs, having its function lessened by the effect of a shock. In addition to 
this, the customary use of opium in some of its forms, after these operations, 
tends to lessen the amount of urinary secretion. When, however, the sup- 
pression is complete, the danger cannot be over-estimated. In addition to the 
lumbar pain, vomiting, feeble pulse, and cadaveric appearance which accom- 
pany the suppression, the perspiration, breath, and alvine evacuations of the 
patient all emit an unpleasant urinous odor. 
Treatment.-Many of the unfortunate sequelae of urethral surgery may 
be avoided by a judicious preliminary treatment. The state of the kidneys 
should be carefully inquired into before any course with reference to treat- 
ment is adopted, and when disease is discovered to exist in these organs, the 
soundness of which is so necessary to successful instrumentation, any opera- 
tion of a violent nature will be presumptuous. Not the least important among 
preparatory measures is rest. This includes freedom from all excitement of 
both body and mind for two or three days antecedent to the contemplated 
operation. The patient will do well to remain quietly in his quarters, 
diminish the amount of animal food, avoid all stimulants, and keep the bowels 
in a regular state. If the rest is much disturbed in consequence of local 
irritation, an anodyne draught may be taken at bedtime, preceded by a warm 
hip-bath. 
Persons whose general health has been shattered by protracted suffering 
may require, in addition to the above management, the use of tonics, as iron, 
quinine, and an improved diet. Quinine exerts, it is thought, a very marked 
influence in preventing urethral fever. It was first administered for this pur- 
pose by Bricbeteau, in 1847, and has the sanction of Gross, Otis, Gouley, and 
many other distinguished names. While I have not witnessed,the prophylactic 
effects of the drug in quite so striking a manner as has been observed by some 
others, I am not disposed to under-estimate its value, believing that it is far 
from being powerless in preventing the rigors which succeed urethral opera- 
tions. To obtain the full benefit of the remedy it must be given half an hour 
before the use of instruments, and in doses of not less than ten or twelve 
grains. When the operation is one likely to be tedious and painful, ether 
should always be administered. I am not to be understood, however, as 
recommending quinine and anaesthetics in a simple procedure like that of 
gradual dilatation. Except in persons of a supersensitive organization, 
this operation can be conducted without creating much local or general 
disturbance. 
As these urethral rigors frequently appear at the time of the first urina- 
tion succeeding the use of the instrument, it is an excellent precaution to 
draw the urine with the catheter immediately after the operation, which 
will render its discharge by the natural passage unnecessary for some time. 
Two other agencies complete the means at our command to prevent the con- 
stitutional effects of urethral instrumentation,-namely, a suppository of 
opium, and hot fomentations applied to the perineum, the genitals, and the 
hypogastric region. Indeed, these last two remedies, with the use of the 
catheter, embody almost everything to be desired. 
When, notwithstanding every precaution, an attack comes on, our atten- 
tion must first be directed to moderate and shorten the chill, if prolonged, 
and, after this has passed over, to lessen and resolve the succeeding fever and 
to maintain an active state of the kidneys. To ameliorate the chill and to 
shorten its duration, little more can be done than to apply external warmth. 
When the reaction sets in, a febrifuge mixture, as the mistura potassae citratis, 
containing a little morphia, with a few drops of tincture of aconite, will prove 
useful: 446 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
R Mistur® Potass® Citratis, ; 
Morphi® Sulphatis, gr. ss; 
Tinctur® Aconiti, gtt. xx. 
M. Sig.-Tablespoonful every two or three hours. 
When the signs of urinary suppression appear, the most energetic meas- 
ures must be employed in order to supply other routes for the elimination 
of those materials which can only permanently be removed from the system 
by the renal organs, until the functions of the latter have been resumed. 
These vicarious routes are the skin and the intestines; and to use them to the 
best advantage recourse must be had to a saline cathartic, together with the 
free use of diaphoretics, assisted in their action by a hot bath or air-bath. I 
have used in some instances, with success, a poultice consisting of leaves of 
digitalis and flaxseed-meal, applied over the lumbar region. As other remedies 
had been employed without relief, I was disposed to attribute the action of 
the kidneys, in part at least, to this remedy. When pyaemia occurs, it must 
be treated on the principles already described under the head of complicated 
traumatic infective fever. 
Urethral Fistula. 
A fistula of the urethra is an abnormal track, one extremity of which com- 
municates with the urethra and the other with the surface of the skin. The 
track is usually quite narrow, is at first surrounded by granulation-tissue, 
may be straight or sinuous, and in time becomes lined with an adventitious 
membrane. A fistula may occui* at any portion of the urethra. Generally 
it is found communicating with the scrotal or the membranous division of 
the canal. Though the fistula usually has only a single opening at its urethral 
extremity, there may be several branches leading from the former and open- 
ing at different points on the cutaneous surface. The length and course of 
these fistulse vary exceedingly, a circumstance which is largely determined 
by anatomical peculiarities of structure. When situated in the ante-scrotal 
part of the urethra they are short and straight; when in the scrotal portion 
they are rarely very long, and generally pursue an oblique course; while in 
the perineal divison of the canal they are usually of considerable extent, fol- 
low a devious, winding course, and open on the surface at one or more points 
anterior to the anus and 
along the sides of the 
raphe, or forward between 
the scrotum and the thigh. 
(Fig. 1254.) The external 
orifices of these fistulae are 
generally small, and when 
close to the raphe of the 
perineum and the scrotum 
are depressed and occupied 
by a crop of granulations, 
which sometimes rises into 
a little conical eminence. 
The discharge which flows 
from these channels may 
be slight or profuse, has a 
slightly yellow appearance, 
in consistence resembles 
water or thin lymph, and is sometimes stained with blood. When attacked 
by acute inflammation, to which these fistulas are very prone, the discharge 
becomes abundant and purulent in character. 
In the early history of a fistula there will be found considerable inflamma- 
tory infiltration, tenderness, redness, and swelling, 'which reveal the mischief 
in progress, and finally culminate in the formation of abscess. 
After the contents of the latter are evacuated, these symptoms subside, and 
Fig. 1254. 
Urethral fistulas opening on the perineum. URETHRAL FISTULA. 
447 
the parts apparently return to their natural condition, the opening contract- 
ing to a small point, which refuses to heal, and through which a portion of 
the urine (it may be only a few drops) escapes during urination, revealing the 
nature of the malady. In fistulse of long standing, the frequent attacks of 
inflammation to which they are exposed render their sides dense and gristly 
from the plastic deposits which have occurred, and which in no small degree 
complicate their cure. 
Causes.-The causes of urethral fistula) are external and internal. Among 
the former are contusions, lacerations, shot and other wounds, and chancrous 
or cancerous ulcerations; among the latter, strictures of the canal, impaction 
of calculi, the rude use of instruments, and the prolonged wearing of cathe- 
ters or bougies. 
During the late American war a large number of urethral fistute followed 
shot lacerations, many of which were utterly intractable to treatment. 
Diagnosis.-:The diagnosis of this disease is not a matter of any difficulty. 
The existence of an external opening, and the escape from it of urine, either 
in drops or in spurts, sometimes in a stream, during micturition, are signs 
sufficient to remove all uncertainty about the nature of the malady. 
Prognosis.-This may be considered from two points, namely, curability 
and danger to life. With regard to the first, much will depend on the situa- 
tion of the fistula, and also on the extent of substance which may have been 
lost, fistula) in the penile part of the tube being much more intractable to 
treatment than those in the perineal portion; though, even when situated in 
the latter, if there is a deep perineum, with much alteration of structure or 
with sinuses extending up between the prostate and the rectum and ramify- 
ing in different directions, the success of operative measures is attended with 
no small degree of uncertainty. 
When, from extensive chancrous ulceration, sloughing, or shot or other 
wounds, there is a considerable loss of substance, though the resources of 
surgery are ample and ingenious to meet the defect, they are exceedingly 
liable to fail. Notwithstanding the condition of a patient suffering from 
urinary fistula is a most pitiable one, from the difficulty of preserving per- 
sonal cleanliness, the immediate danger to life is not great. Yet, should it be 
allowed to remain without control, or prove defiant of treatment, the second- 
ary effects of the disease are of such a nature, when the perineal part of the 
canal is involved, as eventually to undermine the health and to wear the 
patient out by inducing abscesses, cystitis, or disease of the kidneys. 
Among other evils attending the disease may be that of impotence, from 
the semen not passing.tbrough the external meatus of the urethra, stalactitic 
formations deposited by the urine in the course of the fistulous track, and 
ulceration into the rectum (urethro-rectal fistula). 
Treatment.-Obviously, the first thing in the consideration of a case of 
urethral fistula is to ascertain the cause of the disease. If it originates from 
stricture, which is a very common cause, the restoration of the canal to its 
original capacity must take precedence of all other measures. When this 
has been effected by the usual plans of treatment proper to stricture, the next 
object must be to prevent any water from entering the fistula during urina- 
tion. For this purpose the patient must be instructed to perform self-cathe- 
terization, using the instrument as often as may be necessary during the 
twenty-four hours. It is always desirable to have fixed times for this opera- 
tion. If done irregularly, the patient is liable to be taken by surprise and in 
his haste either injure the urethra or allow a portion of the urine to get into 
the fistula. If this treatment is carried into effect faithfully, many cases of 
fistula will close up spontaneously. 
Should this event not follow, a careful inquiry must be instituted, to ascer- 
tain from what causes the failure proceeds. 
Those most likely to exist are the following: 
First. The absence of live granulating tissue along the fistulous canal, its 
walls being callous and gristly. The rough sensation communicated to the 448 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
fingers by passing a probe along the abnormal tube will disclose this condi- 
tion. When it exists in a moderate degree, and the track is not too long, the 
defect may be remedied by carrying a crayon of nitrate of silver or sul- 
phate of copper along the fistula once every three or four days, and in this 
manner revivifying the surface. For the same purpose, when the fistulous 
tube is long, injections of nitrate of silver or sulphate of copper-thirty or 
forty grains of the salt to the ounce of distilled water-may be used; or 
a silver probe dipped into nitric acid or acid nitrate of mercury can be 
employed. 
In small fistuhe situated in the penile part of the urethra, particularly its 
ante-scrotal portion, Dieffenbach recommends what is termed a subcutaneous 
or lace suture. The edges of the fistula are first freshened by vesication 
and scarification, after which a needle bearing a silk thread, by being alter- 
nately introduced and again brought out, surrounds the abnormal orifice 
three-eighths of an inch distant from its border with a thread, drawing upon 
the ends of which makes the ligature subcutaneous and puckers together 
the sides of the fistula. The thread, after being secured, may be allowed to 
remain about four days, when it may be removed. 
Should these means not prove successful, and the fistula is located in the 
spongy or penile part of the urethra, its edges should be pared, brought to- 
gether, and retained over a soft catheter introduced into the bladder either by 
interrupted silver sutures or by twisted sutures. The catheter must be al- 
lowed to remain four or five days (if tolerated) without being removed, by 
which time the union should have taken place. In some cases of this kind 
I have employed the quilled suture, which supplies a very uniform pressure 
to the sides of the wound. (Fig. 1255.) If the tissues are 
at all scant, it will be necessary to dissect up lateral flaps 
before applying these sutures. Erections must be con- 
trolled by local applications of cold water, bromide of 
potassium internally, and anti-aphrodisiacal suppositories. 
In the perineal portion of the urethra, callous fistulse are 
not likely to yield to any remedy short of laying the parts 
freely open from the surface along the fistula into the 
urethra, packing the wound with lint in order to secure 
a continuous granulation from the bottom, and, after the 
chasm is pretty well filled up, beginning the periodical use 
of the catheter, as in cases of laceration of the urethra. 
If there is more than one fistulous track, each in turn 
must be treated by incision. 
Second. The closure of the fistula may be prevented by 
surrounding adhesions, or by the disturbing influence of 
muscular action; and in those opening on the perineum 
and involving the membranous portion of the urethra, 
this is likely to be the case. In this event a perineal sec- 
tion becomes necessary, and the fistula must be compelled 
to granulate from the bottom of the wound. 
Third. The fistulous canal may become incrusted with 
calcareous matter from the urine, which will prevent the 
union of its sides. The pressure of this matter can be 
detected by a probe, or by the grating sensation communicated by the probe. 
The deposition can be dissolved by injections, along the sinus, of dilute 
hydrochloric acid, or by scraping its surface with a miniature curette or 
scoop. 
In the case of an English engineer, who had been twice cut for stone in 
Wales, and who suffered from urethral fistula which had obstinately refused 
to heal, I discovered and extracted a long, spike-like stalactite from the track, 
after which the opening closed up. 
Fourth. The membranous part of the urethra, when it is the seat of fistulse, 
may become united, by inflammatory deposits, to the rectum; and, ulceration 
Fig. 1255. 
Fistula in the penile 
part of the urethra closed 
by quilled suture. URETHROPLASTY. 
449 
setting up, the two canals may communicate, interchanging their contents, 
the urine finding its way into the bowel, and the flatus of the latter escaping 
into the urethra. This condition constitutes a urethro-rectal fistula. When 
the communicating opening is very small, a bilateral incision should be 
made across the perineum, in front of the bowel, and the two canals care- 
fully dissected apart, after which the perineum must be divided from the 
surface along the false passage to the urethra. Both incisions will require to 
be loosely packed. If, however, the opening into the rectum is not large 
enough to receive the end of a small catheter, it will require to be laid open, 
as in ordinary fistula in ano. 
Urethroplasty. 
In cases of fistula attended with considerable loss of substance, resort may 
be had to urethroplasty. This operation, which consists in raising a flap of 
integument from parts adjoining the fistula and turning it into the abnormal 
opening, was long ago attempted by Sir Astley Cooper, and later by the 
French surgeon Delpech. Rieffenbach, Alliot, Ricord, Nelaton, and others 
have given considerable attention to similar operations, which, though 
well worthy of trial, do not, judging from my own experience, promise 
a very flattering success. Czerny has collected 82 cases of operations for 
the closure of urethral fistulte, with only 35 cures, leaving a failure of 58.9 
per cent. In carrying into effect an operation of this kind, the edges of the 
fistula must, in the first place, be well denuded, so as to supply a raw surface 
of considerable extent adjoining the fistula. A flap must next be marked 
off of the same form as the opening to be filled, (but considerably larger), 
which, after being dissected up, leaving a sufficient base for the supply of 
blood (Fig. 1256), is turned into 
position, and its edges united with 
those of the fistula by a num- 
ber of interrupted fine animal or 
silk sutures. Wire is too stiff to 
admit of nice adjustment. Nela- 
ton performed an operation in 
which, after making two transverse 
cuts and vivifying the edges of the 
opening, the flaps were dissected 
up subcutaneously. (Fig. 1257.) 
Alliot's operation, which carries 
the line of approximation away 
from the fistulous opening, consists 
in freshening a considerable surface 
on one side only of the fistula, and, 
after raising a square flap exclu- 
sively from the opposite side, draw- 
ing the latter across the opening and 
stitching it to the margin of the 
denuded side. In all of these pro- 
cedures it is necessary to retain a 
soft catheter in the bladder until the result of the operation is determined. 
As the principal cause of failure in all these operations is the contact of 
the urine with the wound, which, in spite of the catheter, it is almost im- 
possible to prevent, it has been suggested by Ricord, who himself adopted 
the plan in one case (a similar operation has been done by Segalus and by 
Thompson), to open the membranous part of the urethra through the peri- 
neum and allow the urine to flow by this route until the union of the fistula 
has been effected. The magnitude of the evil is sufficiently great to justify 
a resort to this device, although its true value must as yet be considered as 
undetermined. 
Fig. 1256. 
Fig. 1257. 
Urethroplasty. 
Nelaton's operation for 
closing urethral fistula. 
vol. ii.-29 450 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Persons who suffer from incurable fistula) of the urethra, opening on the 
surface of the perineum or scrotum, should lead an exceedingly temperate 
life, using a plain, substantial diet, and protecting the feet and body during 
cold and damp weather by warm clothing. Indifference on these points will 
be followed by alterations in the quality of the urine, which occasion inflam- 
matory attacks in the course of the fistula, accompanied with severe local 
and constitutional disturbances. These, when they occur, are most properly 
managed by rest in the recumbent position, the use of refrigerant diluents, 
and hot fomentations or poultices applied directly to the parts. To prevent 
excoriation from the dribbling of the urine, the skin may be anointed with 
oxide of zinc ointment, and a broad T-bandage worn between the limbs. 
Malformations of the Urethra. 
Many of the malformations which have been enumerated by writers are 
exceedingly rare, and are to be regarded indeed as anatomical or physio- 
logical curiosities rather than as subjects of surgical interest. 
These deformities may affect the position, form, and size of the meatus, or 
of other portions of the canal. 
The meatus may be on one side of the glans; it has been seen above the 
pubes, and also in the groin. Instead of being a vertical slit, it may be round 
or irregular. It is sometimes unusually capacious, but more frequently pre- 
ternaturally small. The latter condition is often an acquired defect in old 
men. Whether congenital or acquired, if it in any way impedes the easy dis- 
charge of the urine, the meatus should either be dilated by graduated bougies 
or incised, and afterwards prevented from contracting during healing by the 
daily use of a bougie. 
Multiple meatuses have been observed, but, so far as I know, only one com- 
municating with the urethra, the others either being slight depressions or 
terminating in a cul-de-sac. 
Atresia of the meatus may be due to a soft adhesion of the sides of the 
opening, as is frequently seen in the labia of female children, or the occlusion 
may consist of a membrane more or less dense. The obstruction, though for 
the most part confined to the meatus, occasionally extends some distance 
into the glans. When the adhesion is soft it can be broken up by the end of 
a probe, but when of firmer consistence it will require incision and subsequent 
dilatation. 
Entire absence of the urethra is associated with exstrophy of the bladder, 
or with its absence, the ureter terminating in the rectum. Partial absence 
of the urethra is sometimes seen in cases of hypospadias, and is limited 
wholly to the glans. It may become necessary to make an opening by a 
trocar, after which a soft bougie should be introduced and retained until 
the surface is healed. There are no examples recorded of a double urethra, 
except in the rare instances where two penile organs have existed. 
Portions of the canal are occasionally found abnormally enlarged or con- 
tracted. Thus, the fossa navicularis may be greatly exaggerated in size, form- 
ing a considerable pouch; and the same condition is witnessed in the prostatic 
sinuses. Such abnormities would favor the formation of urethral calculi. 
The opposite condition may be present, in which scarcely a trace of the scaph- 
oid form of these two portions of the canal remains. 
In the prostatic portion of the urethra the veru montanum may be un- 
usually developed, causing a serious obstruction to the channel. In a few 
instances this part of the urethra has passed above or below the prostate 
body, instead of passing through it. Any obstruction of the urethra, whether 
congenital or acquired, eventually reacts on the other parts of the urinary 
apparatus by causing dilatation of the bladder, the ureters, and even the 
pelvis of the kidneys. 
Hypospadias.-In the development of the penis during embryonic life the MALFORMATIONS OF THE URETHRA. 
451 
position of the future urethra is indicated by a groove, the sides of which 
gradually close in until they finally coalesce, constituting a canal. The 
process advances from behind forward. When this lateral approximation 
becomes arrested, the defect is called hypospadias, from the Greek words 
otto, " under," and <ra-dCw, to " open." 
Hypospadias is therefore a congenital deficiency in the lower wall of the 
urethra, the latter terminating at the frsenum prseputii, or at any point 
between the fraenum and the scrotum. A smooth gutter extends from the 
termination of the urethra forward to the extremity of the glans penis, indi- 
cating the upper wall of the canal, or it may terminate at the base of the 
glans, the latter being perfect and perhaps containing a rudimentary meatus. 
When the former is the case, the head of the organ presents a flattened ap- 
pearance. When the urethra terminates near the root of the penis, it will be 
found in connection with a bifid scrotum. 
In extreme cases of hypospadias the cleft, with a testis inclosed in its 
scrotal sac on each side, strongly resembles the external genitalia of the 
female. In one instance of this kind, where the remains of the penis were 
buried in the groove, the deception was so complete that the medical at- 
tendants informed the parents that the child was a girl, and, on the strength 
of this opinion, it was baptized as such. Nor was the error detected until 
a long time after, when the development of the penis revealed the true sex 
of the child. 
Hypospadias is frequently associated with a preternaturally short corpus 
spongiosum, in consequence of which the organ is incurvated in a downward 
direction. 
Hypospadias, when seated far back in the scrotum, renders its possessor 
fruitless, though not impotent. I treated successfully a gentleman, fifty 
years old, who had a large family of children, and in whom the urethra 
terminated one inch and a half back of the usual location. He was led to 
apply for relief on account of a troublesome vesical irritation, which he 
properly attributed to this cause. I have noticed a similar irritation to 
result from hypospadias on more than one occasion. 
Treatment.-No operations in surgery are more unsatisfactory than those 
done for the cure of hypospadias, and yet there are many favorable cases, in 
which, by patience and perseverance, excellent results can be reached. 
The most promising cases are those in which the urethra terminates near 
the glans, and where the spongy body is not short, giving rise to a down- 
ward curve. 
It is always better, before attempting any operation, to allow the child to 
reach four or five years of age. As it is the urine coming in contact with 
the wound which renders our efforts abortive, I always leave the orifice 
of the abnormal urethra undisturbed, turning my attention wholly to the 
construction of the defective portion of the canal: if successful in this, the 
other can be conjoined with the latter by a second operation. By adopting 
this plan the urine is kept from defeating the union of the flaps, and the 
use of the catheter is avoided. 
Persons suffering from very slight degrees of hypospadias sometimes are 
annoyed by an irritation at the orifice of the urethra, in consequence of a 
slight protrusion of the mucous membrane; they may also have vesical irri- 
tability. When no such inconvenience is experienced, and the person can be 
reconciled to his infirmity, it is not advisable to interfere. 
There are two operations which I think are peculiarly well adapted to 
remedy the defect, and in neither of them is any tissue removed. The first 
consists in making two longitudinal incisions at the juncture of the skin 
and mucous membrane of the urethral gutter, one on each side, and 
then dissecting up flaps in an outward direction. These flaps, after being 
raised and their raw surfaces everted, are to be brought in contact with each 
other over a short lead or soft gum catheter of small size, and retained by 
either the quilled or the interrupted suture. When the deficiency is limited 452 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
to the glans penis, it will suffice to pare off a thin stratum of tissue on 
each side, and bring the edges together over a small catheter by means of 
deep silvei' sutures. The stitches should be removed on the fourth day, and 
also the catheter, or the latter may be taken away immediately on com- 
pleting the operation, as its chief value consists in supplying a resisting 
medium over which to model the urethral arch. Should the attempt prove 
successful and the union of the flaps be consummated, in three or four months 
the second operation may be undertaken,-that of joining the old orifice of 
the urethra with the newly-constructed portion of the canal, and making 
the two continuous. 
For this purpose, after introducing a catheter into the bladder, the incisions 
on each side of the crevice or chasm must be made transverse, taking care 
not to cut into the urethra, and, after dissecting the delicate flaps in opposite 
directions for a short distance, they are to be stitched togethei' by fine silk 
sutures, previously well waxed. 
The second method of closure is by one long and one short flap, the former 
being reversed so that the cutaneous surface is placed next to the urethra. 
A longitudinal incision is made on one side of the urethral defect, from three- 
eighths to five-eighths of an inch from its margin. The integument is next 
dissected a short distance in the direction of the urethra. A second incision, 
parallel with and running along the border of the canal, is made on the 
opposite side, and the flap raised for a short distance outward. The long 
integumental flap is now reverted, raw surface upward, carried across, and 
slipped under the flap of the opposite side, where it is to be secured by 
sutures. The short catheter is to be used, as in the other method, only for 
supporting the tissues by which the chasm is bridged. The stitches may 
be allowed to remain for four, or even five, days. 
A portion of the long flap, that is to say, so much of it as is not covered by 
the short one, must granulate and cicatrize; and it will require several weeks 
before that end is accomplished. As in the first procedure, so in this, the 
junction of the urethral orifice with the newly-formed canal must be the 
work of a subsequent operation. Cold-water dressings constitute the proper 
applications during the after-treatment. Erections must be controlled by 
the use of cold, externally applied, with suppositories of opium, camphor, and 
lupulin. 
Epispadias (from "over" or "above," and to "open") is an 
absence of the uppei' wall of the urethra, and is a much rarer defect than 
hypospadias. 
As in hypospadias, so in epispadias the orifice of the urethra may be in 
the glans penis oi' at any point along the upper surface of the organ. When 
complete, and of course including the membranous and prostatic portions of 
the canal, the disease is usually associated with a congenital absence of the 
pubic symphysis and with exstrophy of the bladder. There is, I believe, only 
a single instance recorded, that of Dolbeau, in which this was not true. The 
position of the urethra above the cavernous bodies in epispadias is difficult 
to reconcile with the usual view of embryologists on the subject of the 
development of the male organs of generation. It probably assumes this 
position by a congenital separation of the cavernous bodies, allowing the 
spongy body to pass between and above. 
Any operation for restoring the upper wall of the urethra will rarely be 
attended with success, and in complete cases, even if successful, does not 
confer on the bladder any power to retain its contents. Successful operations 
have been performed by Liston, Nelaton, and others. 
The method adopted especially by Nelaton consisted in freshening the 
borders of the urethral groove, and then reverting over the canal a flap of 
integument, the cutaneous surface inward, which was covered with a second 
flap taken from the opposite side, the raw surfaces of the two being in con- 
tact with each other. When the integument of the penis was too scanty, FOREIGN BODIES IN THE URETHRA. 
453 
that of the scrotum was utilized by being raised, and, after making a small 
slit corresponding to its raphe, through which the penis was passed, it was 
placed over the raw surface of the other flap, the two forming a covering for 
the canal. Flaps may also be taken from the groins when there is not ma- 
terial enough to finish out the urethra, one being reflected and the other laid 
over its raw surface, and both stitched to the sides of the canal, previously 
freshened. The prepuce may likewise be pressed into service by the surgeon 
in closing the anterior part of the canal, by first paring away the edges of 
the latter, and then making a transverse opening into the prepuce, which 
can be slipped over the glans penis and connected with the denuded sur- 
faces above. The groove in the glans penis is best treated by freshening 
the surfaces immediately external to the margins of the urethra, and then 
bringing them together by the interrupted or a twisted suture, using, in 
case the latter is employed, an exceedingly delicate pin. To accomplish a 
cure in epispadias several operations will be required, not attempting too 
much at a time. The catheter will be necessary during the treatment, though 
the wound is less exposed to the urine than that after the operation for 
hypospadias. 
Foreign Bodies in the Urethra. 
Foreign bodies enter the urethra in two directions, from within outward 
and from without inward. Very rarely do they originate in the canal. 
From within outward.-The substances which descend into the urethra are 
generally renal or vesical concretions or calculi. These bodies are washed, 
during urination, into the urethra, where, in consequence of their size or 
irregularity of form, they become arrested and permanently fixed. If not 
soon dislodged, these calculi increase in size by a continued deposition of the 
salts of the urine, and almost occlude the urethra. In those parts of the 
canal which are normally large, as the fossa navicularis, and especially the 
prostatic portion, these bodies are more likely to be retained, as they are 
removed somewhat from the force of the stream during micturition, and be- 
come moulded to the figure of the channel in which they lie by the addition 
of new material from the urine. I have seen the prostatic sinuses so com- 
pletely filled with a concretion that it must have prevented the discharge of 
either the seminal or the prostatic fluid, as the under surface of the foreign 
body, when removed, proved to be a perfect cast of all the inequalities of the 
flooi' of this part of the urethra. 
Symptoms.-The symptoms of the presence of a calculus in the urethra 
are generally very well defined. They commence suddenly, and generally 
during micturition, when the concretion is swept into the canal. They some- 
times appeal' shortly after an attack of renal colic or follow a crushing 
operation for stone. 
There is a sudden sense of smarting, tearing pain in the urethra, an in- 
creased desire to micturate, attended with straining efforts, and an obstruction 
to the stream of urine more or less complete, the latter being discharged in 
drops or in a number of small, twisted streams which fall at the patient's 
feet. These sensations may last for but a short time, as the body may be 
expelled during the next urination, when all inconvenience will disappear, 
leaving only a little soreness in the course of the canal. When the concre- 
tion is large or angular (in which last case it is likely to become entangled in 
the plications of the mucous membrane of the passage) it may remain for 
several days, the symptoms continuing urgent during the whole period of its 
detention, until at last, by an unusual impulse of the column of water, it is 
disengaged and expelled from the urethra. In other cases it will be found 
that all natural efforts prove unavailing for its expulsion, when it will become 
necessary to employ instrumental measures for its extraction. Such bodies, 
when allowed to remain, are liable to produce inflammation, abscess, and 
fistula of the urethra, retention of urine, and cystitis. A short time ago I 454 
INJURIES AND DISEASES OF THE GENITO-URINARE ORGANS. 
witnessed the death of a patient who perished from the evils incident to a 
large prostatic concretion which had not been detected until the man was 
in a moribund condition. 
If any doubt exists in regard to the diagnosis, it may be solved by an ex- 
ploration of the urethral canal, externally with the finger and internally by 
a catheter or sound. Such an examination will be particularly necessary in 
children, who are unable intelligently to express their sensations, and who 
are frequently the subjects of such attacks. 
If the calculus is lodged in the ante-scrotal portion of the urethra, it may 
often be discovered by the finger pressed along the course of the canal exter- 
nally. When in the membranous portion, a digital examination through the 
rectum may also disclose its presence. For internal examination a medium- 
sized catheter or sound, straight or slightly curved at the vesical extremity, 
is the proper instrument. In children I frequently employ a common pocket- 
case ductor having a smooth and well-rounded end. Whatever instrument 
is selected, it must be well oiled, and carried gently along the urethra until 
it touches the foreign body, which can be readily recognized by the rough, 
grating sensation communicated to the fingers. 
Sometimes it may be necessary at certain points in the canal, where the 
sensations are liable to be misinterpreted, to move the instrument up and 
down several times, changing the direction of its extremity, and making 
counter-pressure externally with a finger, until any doubt which may have 
existed in regard to the diagnosis has been removed. 
Treatment.-It is not necessary in every case of urinary concretion to 
subject the patient to operative interference. If the attack has come on 
within a few hours, a hot hip-bath and the free use of diluent drinks will 
often, by relaxing the muscular contraction of the walls of the urethra and 
increasing the flow of water, suffice for its extrusion. The patient may ren- 
der the column of urine more potent for dislodging the obstruction by com- 
pressing tightly the meatus between the thumb and fingers and preventing 
for a short time the escape of water, a vigorous effort being made at the 
same time to discharge the urine. The distention of the canal in front of 
the foreign body, which is caused by this simple device, may be sufficient, 
when the resistance at the meatus is suddenly removed, to insure its being 
washed out. Not unfrequently, when the calculus is in the anterior part 
of the penile urethra and can be felt externally, the displacement can be 
assisted by pressing the body forward with the finger. In soft uric acid 
concretions I have succeeded in this way in crushing the mass into particles 
without using any force which would do violence to the -walls of the canal. 
When, notwithstanding the use of the above means, the body remains 
fixed, it will become necessary to resort to more active measures; and these 
must be determined by the position of the foreign body in the canal. When 
located in the prostatic urethra and that part of the membranous urethra 
which is behind the triangular ligament, the proper course is to push the 
offending body back into the bladder, wThich can readily be done by a large 
catheter with a well-rounded extremity. If, however, the obstruction is 
situated in the penile portion of the canal, the risks attending its restoration 
by force into the bladder are too great; it must be extracted; and in doing 
this the surgeon should adopt, first, the simplest resources for the purpose. 
Among these the most convenient and efficient is to stretch the urethra in 
front of the stone to its full capacity by graduated bougies. Should this not 
succeed, resort must be had to some of the different ingenious instruments 
■which have been devised for this purpose, in all instances first injecting the 
urethra with a quantity of sweet oil. If the concretion is in the fossa 
navicularis, behind the glans, it may be extracted by an ordinary pair of 
forceps; and when the resistance offered by the meatus to its removal is great, 
a slight incision may be made, provided dilatation proves inadequate for the 
purpose. When the body is not too large and the urethra is sufficiently 
capacious, I am in the habit of using the little scoop which is on one end FOREIGN BODIES IN THE URETHRA. 
455 
of the ordinary director. This can be passed down the canal beyond the 
concretion, when, by applying the concave surface of this instrument to the 
body, the latter may be dragged forward and removed. The process will 
often be facilitated by the counter-pressure of the finger on the outside. In 
like manner may be used the metallic loop of Marini, which is nothing more 
than a smooth, flexible wire, in shape resembling a fenestrated scoop, and 
having its convex extremity bent so as to form a slight curve. 
The articulated scoop of Leroy d'Etiolles is an admirable appliance for 
getting in the rear of an obstruction and dragging it forward. (Fig. 1258.) 
Fig. 1258. 
Articulated scoop of Leroy d'Etiolles. 
This instrument is introduced along the urethra straight, and, after passing 
the foreign body, its articulated end is turned down at any angle desired by 
means of a screw at its opposite extremity. 
In the absence of these instruments, an excellent contrivance may be 
improvised by bending a piece of wire on itself like a hair-pin, spreading 
the loop a little at its convex extremity, and then turning it to a slight 
angle. 
The value of all these instruments will depend on our ability to place them 
behind the obstructing body (Fig. 1259); and, while they are usually very 
efficient, it cannot, I think, be denied that, as in their use the urethra is not 
Fig. 1259. 
dilated in front, the canal is liable to suffer more or less injury by loose folds 
of the mucous membrane being pushed up in front of the body. A second 
class of instruments, having two blades, are designed to embrace the calculus 
on two sides, acting wholly as tractors, or on the principle of the common 
forceps. Such are the instruments of Matthews (Fig. 1260) and of Gross. 
(Fig. 1261.) The latter instruments necessarily, by their expanded blades 
Manner of extracting foreign substances from the urethra. 
Fig. 1260. 
Matthews's forceps. 
Fig. 1261. 
Gross's forceps. 
stretching the urethra in front of the object grasped (Fig. 1262), are safer, 
though less effective, from the difficulty of seizing the foreign body, than those 
already described. A third variety of instruments are those constructed with 
three blades. The forceps which go sometimes by the name of Hunter, and 
at other times by that of Voillemier or of Civiale (Fig. 1263), are of this kind. 456 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
The instrument is introduced with the three blades closed, and when the 
concretion or other substance is reached they are expanded over the periphery 
Fig. 1262. 
Foreign body grasped by forceps. 
of the body, which, by the retraction of the blades, is afterwards firmly em- 
braced in their grasp. 
Occasionally it happens that a stricture in the course of the urethra has 
Fig. 1263. 
Hunter*, or Clrlnle'a forceps. 
prevented a mass of gravel from passing, until finally it has become firmly 
impacted. No efforts can be made for its extraction unless the stricture has 
been fully dilated. When the calculus is so large and so firmly impacted in 
the urethra as to defy extraction by any of the means described, there remain 
only two plans for its removal,-by crushing and by incision. 
Crushing a calculus.-For carrying out the first plan, which is a very ancient 
operation, there are two instruments, the miniature lithotrite of Civiale, or 
an instrument resembling Exeter's ball-extractor, and the drilling lithotrite 
of Paulus JEgineta or of Reliquet. (Fig. 1264.) 
Fig. 1264. 
Keliquet's lithotrite. 
The applications of these instruments are so limited, the difficulty and un- 
certainty attending their adjustment to the foreign body so great, and, above 
all, the danger to the canal so imminent, that they might well be eliminated 
from the surgery of the urethra. 
Incision is a safer and more expeditious method of managing cases of stone 
which cannot be extracted through the normal channel. 
When the concretion is lodged in the membranous or prostatic part of the 
canal, the procedure may be not inaptly compared to that of cutting for 
stone. The rectum should be emptied, and the patient etherized and placed 
in the lithotomy position. A staff is next passed down the urethra to the 
obstruction, when an incision should be made in the raphe, between the 
scrotum and the anus, and carefully deepened until the body is reached. 
The urethra being now opened, the calculus can be extracted by passing 
behind it a scoop or a flat hook, or by introducing a finger into the rectum 
and thrusting it out by pressure from behind forward. The subsequent 
treatment of the wound will be the same in all respects as after lithotomy. 
When the concretion is situated in the penile portion of the urethra, it 
should be exposed and removed by a direct incision, the wound immediately 
closed by the twisted suture, and the urine drawn by the catheter for seven 
or eight days, or until the parts have healed. 
If the scrotal part is opened, it may be found necessary, in order to avoid FOREIGN BODIES IN THE URETHRA. 
457 
urinary infiltration, to separate the two halves of the scrotum and retain 
them apart for thirty-six hours, by which time the union of the parts will 
have sufficiently progressed to prevent extravasation. 
The bodies which are lodged in the urethra from without are either intro- 
duced designedly from a wanton or perverted disposition to trifle with the 
sexual organs, or from accident. In a few instances they have been inserted, 
either from mischief or from downright wickedness, while the patient has 
been deeply intoxicated. Among the materials generally comprised under 
the first head are straws, slate-pencils, hair-pins, pebbles, cherry-stones, leather 
strings, needles, pins, etc. Those which lodge in the urethra from accident 
are, for the most part, portions of soft bougies or catheters. A body once 
in the urethra has, it is believed by many, a strong tendency to travel in the 
direction of the bladder, notwithstanding that the mouths of the lacunae, 
which open forward, and the direction of the stream of water in urination, 
would render such a tendency improbable. For a long time I was skeptical 
in regard to this retrograde movement, except in the case of bodies having a 
particular form or with bristling points, in which case the explanation is plain. 
I have had ocular demonstration, however, of this urethral and vesical deglu- 
tition of substances in which neither of these conditions existed. 
While once operating on the perineum of a private patient, the soft cathe- 
ter (rather a short one), which was in the urethra, suddenly slipped from the 
fingers of an inexperienced assistant, and immediately disappeared through 
the meatus. A cry of surprise from the discomfited nurse called my atten- 
tion to what had occurred. I instantly grasped and firmly compressed the 
penis in my two hands, and by pushing the corpus spongiosum forward with 
one hand, while with the other the organ was pressed backward, I got the 
catheter sufficiently near the meatus to enable me to seize it with a pair of 
forceps. On another occasion, finding the resistance to the extraction of a 
catheter very marked, I proceeded, in order to satisfy myself of the reality 
of the so-called suction power of the bladder and urethra, to dally with the 
instrument for a short time. Accordingly, after pulling it a little way through 
the orifice of the urethra, I would relax my hold, when it would be imme- 
diately drawn in, and sometimes with singular rapidity. This behavior of 
the urethra under the stimulus of foreign bodies introduced from w'ithout 
is the more remarkable as it does not appear to be so influenced by bodies 
which enter it from the opposite direction. As it must operate through a 
reversed action of the muscular fibres which surround the canal, the only 
theory which occurs to me as competent to explain the reversed action in 
the one case and its absence in the other is a probable difference in the effect 
produced in the order of muscular action, according as the irritation primarily 
affects the terminal nervous loops or the nerves nearer their origin. 
Treatment.-The bodies which are introduced into the urethra from with- 
out are so diverse in kind, shape, and consistence that there is opened a wide 
field for the exercise of surgical ingenuity. Round bodies, such as beads, 
cherry-stones, and shot, will be most readily extracted by some of the differ- 
ent forms of scoops already described. Cylindrical or flat substances, as 
lead-pencils, bits of catheters, and pieces of wood or straw, can be frequently 
removed by the urethral forceps, or by the forceps of Luar. (Fig. 1265.) 
Hair-pins, which are almost always introduced with the closed extremity 
downward, are best managed by pressing their points together, grasping the 
urethra between the thumb and fingers, and either seizing the pin with 
the forceps, or, as was done on one occasion by Mr. Avery, slipping over the 
points a piece of gum catheter. The elasticity of the branches of the pin 
when released from the pressure of the fingers is sufficiently strong to make 
it cling to the tube until it is extracted. 
Hydrostatic pressure may be profitably employed for the expulsion of 
bodies which possess regularity of form. For this purpose a small flattened 
canula with a smooth extremity should be passed a short distance behind the 
obstruction. Into the exposed end of the canula is next fitted the nozzle of 458 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
a syringe, and while the water is forced into the urethra the latter is strongly 
compressed about one inch and a half distant from and both behind and in 
Fig. 1265. 
Urethral forceps. 
front of the foreign body. Should the latter not be floated forward, it may 
be moved by sliding the posterior finger forward along the urethra. By 
repeating this process of extreme distention the body may, little by little, 
finally be extruded. 
Beads may be removed by bending the end of a probe into a hook and 
passing it beyond the body, when, on withdrawing the instrument, the point 
is likely to pass through the opening of the bead and both come out together. 
A pin or needle, when sufficiently long to be located and felt, may be thrust 
through the walls of the canal by grasping the urethra at a point answering 
to the head or the blunt end of the body, and then bending the penis back- 
ward to an acute angle, as was done by Boinet in the case of a hair-pin. It 
may then be drawn through, or, if the head will not admit of this, the sharp 
end may be cut off, and the remaining portion held until it can be secured by 
the urethral forceps and withdrawn through the natural channel. 
Dr. Keyes, of New York, has suggested, in such cases, the feasibility of ex- 
traction by a Thompson's divulsor, the branches of which being opened and 
again screwed together might possibly catch the offending body. Another 
plan, which it has occurred to me might be practicable if the pointed body 
lay free in the urethra, is the introduction of a metal tube like a catheter, 
its end large and open, and filled for a short distance (immediately before 
being introduced) with plaster softened with water; then, while fixing the 
pin with the fingers on the outside of the urethra, the instrument should 
be carried along the canal down to the foreign body. Should we be for- 
tunate enough to include its extremity in the soft plaster, the latter, as soon 
as it became hard (the work of only a few minutes), would hold the pin with 
sufficient firmness to allow of its being removed. 
Tumors of the Urethra. 
The male urethra is rarely affected by morbid growths. Those which 
occasionally exist are of three kinds, namely, polypoid, vascular, and papillary. 
Polypoid Growths are olive-shaped or oblong, with pedunculated attach- 
ments. The surface may be smooth and pale, or red and granular. Though 
no part of the canal can be said to be exempt from such tumors, the fossa 
navicularis and the prostatic portion are generally the favorite locations 
for their development. They may be single or multiple, consist of fine in- 
terlacing threads of connective tissue and blood-vessels, and, beginning in 
the submucous tissue of the urethra, are covered with an attenuated layer 
of its mucous membrane. They seldom give rise to any pain, and may exist for 
some time without being suspected. They at length provoke frequent mictu- 
rition and vesical tenesmus, offering considerable impediment to the flow of 
the water, so that the patient is unable to project his stream any distance 
beyond the meatus, or it may be divided into several small streams. When 
the tumor is in the navicular fossa, it may be exposed to the eye by expand- 
ing the sides of the urethra behind the meatus with the blades of the dress- URETHRITIS. 
459 
ing forceps. When seated deeper in the canal, an exploration with a soft 
bulbous bougie may reveal its existence, by the hitch which is felt when the 
body is passed in withdrawing the instrument. 
Treatment.-Urethral polypus is most effectively removed by being grasped 
between the blades of a urethral forceps as close as possible to its base, and, 
by repeated turns of the instrument, twisted off from its attachment. This 
is not a difficult task when the growth is in the navicular fossa ; but when 
located farther back it is the work of patience and much delicate tact. The 
silver canula and wire noose used by Cloquet in extracting foreign bodies 
from the urethra may be advantageously employed for this purpose. The 
removal of these tumors is attended with no serious hemorrhage, and, if the 
bleeding should be protracted, cold and pressure around the organ, either 
with or without the use of the catheter in the canal, will be preferable to the 
use of cauterizing and astringent remedies internally. 
Vascular Growths.-These tumors, quite common in the female urethra, 
may in rare instances be found in the male urethra, and, so far as my own 
observation goes, are located immediately within the meatus. The growth is 
red, spongy, somewhat flattened, and less sensitive than similar formations in 
the female. Its base may be broad or narrow, and in micturition it may pro- 
trude slightly through the external meatus. These growths do not differ in 
histological formation from those seen in women, being made up of a com- 
plex net-work of blood-vessels, connective tissue, and nerves, covered with 
urethral epithelium. They will be more particularly considered under the 
head of diseases of the genito-urinary organs of the female. 
The treatment consists in excision, with cauterization of the raw surface 
left by nitric acid, which should be followed by the injection of sweet oil 
into the canal. 
Villous or Papillomatous Growths are next in frequency to the polypoid; 
they are not necessarily confined to any particular division of the urethra, and 
may be scattered along its entire length; the tumors, varying in size from a 
hemp-seed to a marble in the male, are made up of filamentous prolongations 
consisting of blood-vessels and connective tissue and presenting an arbores- 
cent or a cauliflower appearance. 
These growths are capable of inducing the most severe vesical tenesmus, 
often attended with loss of blood. 
Evulsion or strangulation and subsequent cauterization constitute the 
proper treatment. 
Urethritis. 
Urethritis occurs both as a non-specific and a specific inflammation of the 
mucous membrane of the urethra; these, though having many points of 
resemblance, are nevertheless entirely distinct affections. 
Non-Specific Urethritis is characterized by heat, fullness, and tenderness 
along the course of the urethra, with some muco-purulent discharge, and a 
smarting or scalding sensation during micturition. 
Causes.-The inflammation is frequently the result of sexual intercourse, 
and produced by the irritating effect of leucorrhceal and menstrual discharges 
on the mucous membrane of the urethra. It is often occasioned by excessive 
venereal indulgence, by exposure to cold, especially in persons of a lymphatic 
temperament, by the presence of urethral stricture, foreign bodies in the canal, 
stone in the bladder, hemorrhoids, by the use of hot aromatic substances, and 
occasionally by the administration of certain drugs, as turpentine, balsam 
of copaiba, guaiac, and iodide of potassium. 
Alterations in the constitution of the urine will also serve to give rise to a 
simple urethritis, as in cases of oxaluria, or in the lithic acid diathesis, the 
inflammation being the result of mechanical irritation produced by the crys- 
tals of oxalate of lime or uric acid on the mucous membrane of the urethra. 
The diagnosis of non-specific urethritis will be considered under the head 
of gonorrhoea. 460 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Treatment.-In the treatment of non-specific urethritis it is of the first 
importance to ascertain the cause of the malady, and, if possible, to effect its 
removal. If it results from contact with irritating vaginal or uterine secre- 
tions, sexual abstinence and cleanliness is all that is necessary. If stricture 
of the urethra exists, it must be removed by treatment appropriate to cases 
of this nature. If it arises from the employment of certain medicinal agents, 
or from disturbances of the digestive organs, leading to mal-assimilation of 
the food and to changes in the character of the urine, in the one case the 
use of the suspected drugs must be suspended, and in the other the evil 
must be corrected by a properly regulated diet, avoiding fats and sugars, by 
exercise, and by the adoption of such remedies as are calculated to correct 
the state of the urine. Among these may be enumerated infusion of gentian 
or quassia, nitro-muriatic acid, phosphoric acid, bicarbonate of potash, and, 
possibly, chalybeates. 
Very little local treatment is demanded. The discharge usually disappears 
spontaneously in the course of eight or ten days. Should it linger, it may 
be removed by mild astringent injections of green tea, rose-water, or acetate 
of lead (half a grain of the acetate to one ounce of water). 
Specific Urethritis, or Gonorrhoea, is the most common of all venereal dis- 
eases. The term gonorrhoea (derived from the Greek yov-q and meaning 
a flow of semen), like many others in our medical nomenclature, has been 
badly chosen. But as common usage, independent of etymological incon- 
gruity, has affixed to the word a definite meaning, there does not appear to 
be any urgent necessity for changing the term. The Saxon word clap is the 
vulgar synonym for the disease. 
Gonorrhoea is an inflammation of the mucous membrane of the urethra, 
accompanied by a contagious muco-purulent discharge. Though at one time 
supposed to be a syphilitic disease and dependent on urethral ulceration, 
it has been established beyond controversy through the observations and 
experiments of careful observers, especially those of Ricord, that, except in 
the manner in which gonorrhoea is contracted, the two diseases have no re- 
lationship. Gonorrhoea is purely a local affection, and wholly powerless to 
produce any constitutional taint. 
Causes.-While I do not deny the possibility of a specific urethritis origi- 
nating from the contact of the mucous surface of the genitalia with infected 
clothing, such instances must be very exceptional. The disease is almost 
always caused by sexual intercourse, one of the parties to the act suffering 
at the time from gonorrhoeal inflammation. There is no evidence that the 
disease ever arises from contact with the ordinary vaginal or uterine dis- 
charges, as leucorrhoea or the menstrual fluid, or that it can be induced by 
sexual excesses. There are but two conditions requisite for its development, 
-namely, the presence of a specific virus or poison, and the application of 
that poison to some portion of the mucous membrane of the genital organs. 
This virus is capable of producing a specific form of inflammation not only 
when brought into contact with the mucous tissue of the penis and prepuce 
of the male and the vagina and urethra of the female, but also when applied 
to other mucous membranes, as those of the eye, the uterus, the bladder, and 
the rectum. Whether the lining membrane of the mouth and nasal passages is 
equally vulnerable to the action of the poison has not yet been satisfactorily 
determined. Of the susceptibility of the rectal mucous surface there can 
be little doubt. Allingham and other writers have recorded several cases of 
rectal clap in the persons of prostitutes. 
The conditions which predispose to gonorrhoea are a large meatus, hypo- 
spadias, a redundant prepuce, which serves to retain the vaginal discharges, 
and prolonged oi* frequently repeated intercourse. 
Nature of the virus.-The most careful examinations, chemical and micro- 
scopical, fail to discover in the products of gonorrhoeal inflammation anything 
different from ordinary pus. There are reasons for believing that the peculiar SPECIFIC URETHRITIS, OR GONORRHOEA. 
461 
materies which confers the specific property on gonorrhceal matter is inti- 
mately related to the pus-corpuscle, as the experiments of Rollet tend to 
show that the liquor puris and the mucous constituent of the discharge, when 
separated by filtration, possess no infecting quality. Still, it remains true, as 
in the pus of chancroid, that there Jias been no isolation of any substance 
which can be identified as the cause of the mischief. 
After exposure from impure connection, a period elapses between the ap- 
plication of the gonorrhoeal matter and the development of the disease, which 
is the stage of incubation or latency, a period subject to considerable variation, 
sometimes not exceeding twenty-four hours, at other times lasting for eight 
or nine days. In a few instances well-defined symptoms have been observed 
six hours after intercourse. Fifteen or sixteen days may be regarded as the 
utmost limit of dormancy. The usual period for the development of the 
disease is between the fourth and the seventh day. 
Symptoms.-The earliest objective evidence of inoculation is a certain 
feeling of uneasiness at the urinary meatus, which gradually assumes defi- 
niteness in an itching, worrying irritation. On examination the labia of the 
meatus will be found slightly tumid and red, and perhaps glued up with a 
viscid secretion. As this gluing discharge increases, the uneasiness at first 
felt in the region of the meatus extends farther back along the urethra, giving 
rise to a sense of fullness and weight in the penis, and is accompanied with 
severe pain, heat, and scalding on passing water, in addition to which the 
orifice of the urethra feels raw, burning, smarting, and sore. 
The discharge which is first observed is the product of the mucous follicles 
of the urethra, their secretion being increased by the local irritation. 
In the course of four or five days from its first appearance the discharge 
becomes copious and purulent, being at first slightly yellow, and finally 
greenish, and not unfrequently, when inflammation runs high, stained with 
blood, from the rupture of the overstrained vessels of the mucous membrane. 
As the inflammation approaches the zenith of its intensity the entire organ 
becomes tendei' and swollen, and the stream of urine is diminished in size, in 
consequence of the submucous infiltration narrowing the lumen of the canal. 
The glans penis is particularly red, and the prepuce oedematous, and the 
patient is harassed with troublesome erections and a frequent desire to mic- 
turate. 
Sometimes there is complete retention of urine. This may arise from great 
irritability and spasmodic contraction of the muscles of the membranous and 
prostatic portions of the urethra, or from inflammatory swelling of the 
prostate body. 
When the deeper parts of the canal are involved, there are fullness and sore- 
ness in the perineum, and not unfrequently in the groins, attended with 
swelling in the inguinal glands. When the inflammatory symptoms are more 
than ordinarily severe, the constitution sympathizes in the local disturbance, 
giving rise to increased heat of the general surface, thirst, fever, and nervous 
restlessness. 
After the lapse of from ten to twenty days, the disease reaches its cul- 
minating point, when the symptoms begin to abate. The discharge lessens 
in quantity, becomes thinner and paler, and at length amounts to only a few 
drops, which collect in the meatus or glue togethei" its sides, or which are 
rendered visible only by pressing with the fingers the deeper portions of the 
urethra, where the inflammation lingers longest. 
With the subsidence of the discharge, the urgent desire to urinate and the 
smarting attending the act, together with erections and chordee, disappear. 
The time generally required for the declination of the inflammation is seldom 
less than eight or ten days. There are, therefore, three quite natural stages 
in the curriculum of gonorrhoeal disease,-a stage of incubation, one of de- 
velopment and maturation, answering to the acute inflammatory stage of 
writers, and one of declination, the three stages ordinarily requiring for their 
completion from five to six weeks. 462 
INJURIES AND DISEASES OF THE GEN ITO-URINARY ORGANS. 
The inflammation, which, in the male, commences at the meatus urinarius 
and slowly creeps backward, seldom, if not interrupted by treatment, reaches 
the whole length of the spongy part of the urethra earlier than about the 
sixteenth day from its development, and manifests a tendency to linger in 
the deep portion of the penile urethra and in the navicular fossa even after 
all traces of the disease have disappeared from the intermediate portions of 
the canal. Inflammation, however, is not limited to the spongy urethra. It 
may travel to the bladder or over the glans penis (balanitis), or to the under 
surface of the prepuce (posthitis). 
Pathology.-The pathological changes which characterize the progress 
of the disease are similar to those witnessed in acute catarrh of the mucous 
membranes. The vessels of the mucous membrane lining the canal, the fol- 
licles and lacuna?, are found deeply congested, giving a red, shining appear- 
ance to the membrane. The submucous tissue is filled with cell and lymph 
infiltration, giving rise to considerable thickening, which at points where the 
inflammation has been very severe is liable to remain and lay the foundation 
for stricture. When the disease has not been actively treated, and passes 
into the chronic state or into a gleet, the papillae of the mucous membrane 
may become hypertrophied, giving rise to granulations which rise above 
the common level of the membrane and furnish a discharge of a light color 
and of the consistence of thin syrup. 
Diagnosis.-As there is a urethritis of a non-specific character, from which 
the purest individual may suffer, it is exceedingly important to be able to 
distinguish it from the specific form of the disease. Is such a differential 
diagnosis possible ? I believe it is; and I feel confident that several times in 
the course of my professional life I have been able to restore the peace and 
confidence of families, where distrust in the fidelity of the conjugal relation 
had no just foundation, but nevertheless threatened the most serious con- 
sequences. 
In simple or non-specific urethritis the inflammation is far less acute, the 
discharge much less copious, and the scalding less severe than in gonorrhoea. 
There is no chordee, and, above all, the disease is never inaugurated by that 
peculiar itching pain at the orifice of the urethra which belongs to gonorrhoea; 
it disappears spontaneously without treatment, seldom continuing beyond 
eight or nine days, and leaving no chronic discharge in its wake. I am aware 
that profuse muco-purulent discharges are said often to accompany simple 
urethritis; but I have never seen such. 
Treatment.-Gonorrhoea, though generally a very manageable disease, is 
the subject of so much empirical tampering that there are few affections 
which entail more moral and physical suffering. The disease furnishes a rich 
harvest for unscrupulous quacks, and men are drawn into the snare like fool- 
ish birds. Physicians themselves are sometimes betrayed into a routine 
method of combating the disease without reference to its stage. 
There are two plans of treatment. The one aims at cutting the disease 
short, arresting it suddenly, and is designated the abortive method. The other 
is a treatment which proposes to accomplish the cure in a more gradual man- 
ner, by the rational use of means adapted to the severity of the stage of 
inflammation. 
The abortive treatment is attempted in different ways. In one, a single 
strong injection (forty grains of nitrate of silver to one ounce of water) is 
thrown into the urethra. Others prefer a daily injection of a less powerful solu- 
tion (ten grains to the ounce of water), and still another class of practitioners 
use quite a weak solution (one-quarter of a grain to the ounce of water), but 
repeat the injection every three or four hours. The employment of a stronger 
solution for the purpose of putting a sudden termination to specific urethritis 
merits, in my judgment, and I am not singular in this respect, the most un- 
qualified condemnation. If it was always employed in the very incipiency 
of the disease, before the inflammation becomes fairly developed, the evil 
would be materially abated; but application for relief is rarely made at this SPECIFIC URETHRITIS, OR GONORRHOEA. 
463 
stage, and hence the common sequels of adding fuel to the flame are epididy- 
mitis, prostatitis, cystitis, stricture, and even peri-urethral abscesses. 
Two things should be kept clearly before the mind of the practitioner in 
treating a case of gonorrhoea: first, that the inflammation, if left to itself, 
is prone to pass from the acute to the chronic state; secondly, that there is 
no specific for the disease. One of the great difficulties which is encountered 
in managing a case of gonorrhoea is the inability, in most instances, to place 
the patient under those hygienic restrictions which are important factors in 
the treatment of any inflammation. These include rest, proper food, drink, 
pure thoughts, and the absence of all mental and physical excitement. 
The disability is not sufficiently great to compel the patient to relinquish 
his daily occupations. In hospitals, where the authority of the physician is 
supreme, and where most of the conditions specified can be enforced, the time 
required for the cure of gonorrhoea is much shorter than in private practice, 
and the complications are less common. 
In the first stage of the disease, when the irritation is confined to the 
urethral orifice, and the mucous discharge is just making its appearance, the 
patient should be advised to relinquish business and go to bed for a few 
days. There will be much time saved in treatment if such obedience can 
be exacted. Whether this advice is followed or not, the diet should be care- 
fully regulated, all stimulating articles of food and drink being discarded, 
and should consist chiefly of milk, bread, butter, tea, and fruits, unless the 
patient is pale, anaemic, and broken in health, when the nourishment must 
be more liberal. The bowels should be kept in a soluble condition by a 
saline aperient, for which purpose a tablespoonful of a solution of bitartrate 
of potash (gi of the salt to §vj of water) may be used three or four times 
a day; and, in order to render the urine as unirritating as possible, the 
effervescing mixture may be directed, or an alkaline diluent, consisting of 
an infusion of slippery elm or flaxseed, to which is added some bicarbonate 
of potash or soda and a small amount of lemon-juice to render the liquid 
more palatable. In addition to these measures, the penis should be lightly 
and frequently dressed in wrappings of old linen, wet with hot water and 
laudanum; and, to protect the glans and prepuce from the irritation of the 
discharge, circular pieces of soft linen, large enough to cover the head of 
the penis, and with an opening cut in the centre, opposite the meatus, should 
be spread with a little oxide of zinc ointment, placed over the glans, and 
kept there by drawing the foreskin forward. This simple contrivance will 
often prevent the occurrence of a balanitis or a posthitis. When the patient 
is a walking one, some attention must be given to the protection of his 
person and clothing from the urethral discharges. For this purpose many 
advise the use of rubber sheaths or condoms; these, however, give rise to 
too much heat: when used, they ought not to be worn in contact with the 
skin, but with a soft rag interposed. A piece of old linen tied over the organ, 
and which can be replaced as it becomes soiled, is a preferable dressing. 
Injections are to be employed two or three times a day, and should be of 
the mildest character, simple warm water or rose-water being the most 
suitable. 
Whether the patient is in bed or walking about, it is advisable to keep 
the penis elevated, so as to empty the vessels of the organ as much as 
possible. 
In from four to six days, under this treatment, the severity of the inflam- 
mation will have been greatly lessened, which may be known by the dimin- 
ished turgescence, scalding, pain, and discharge, indicating the culmination 
of the second and the beginning of the third stage, or that of declination. 
Then we may venture on the use of astringent injections and certain internal 
remedies which exercise a controlling influence over the disease. 
If, however, the inflammatory symptoms do not abate, such agents must 
be withheld, as their use will only aggravate the already too great vascular 
action. In such cases leeches may be advantageously applied to the perineum, 464 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
and fomentations of water as hot as can be borne should be kept constantly 
in contact with the scrotum, penis, and perineum. Half an ounce of neutral 
mixture, each dose containing one-sixteenth of a grain of morphia and four 
drops of the tincture of aconite, should be given every three hours until the 
urgent symptoms have been subdued, when, after an interval of two or three 
days, the urethral medication may commence. 
A great variety of articles are employed as injections, the most popular 
being acetate of lead, sulphate of zinc, acetate of zinc, sulphate of copper, 
nitrate of silver, tannic acid, and alum. 
No one of these injections will answer in every case. They require to be 
changed; but, in my own experience, the sulphate of zinc has proved, in a 
majority of cases, the most satisfactory. 
It is necessary to begin always with a weak injection, increasing the 
strength according to the tolerance of the urethra. When the smarting fol- 
lowing its use is severe, or even not severe, but prolonged, the proper limit 
of strength has been exceeded. Half a grain of the sulphate of zinc to one 
ounce of water is quite strong enough at first, and, if well borne, it may be 
increased gradually to five or six grains; and the same rule may be observed 
for the acetate of lead. If the nitrate of silver is employed, one-fourth of a 
grain to the ounce of distilled water may be regarded as the minimum and 
two grains as the maximum strength of the injection. These remedies should 
be used three times a day, always directing the patient to urinate before they 
are thrown into the urethra, in order that the canal may be washed out, and 
that the fluid may act directly upon the inflamed surface of the mucous 
membrane. 
Besides the injections which have been enumerated, there are many other 
formulae, each of which has its particular advocate. Among these may be 
mentioned that of Mr. Lloyd,-chloride of zinc, gr. i-ij; water, ,5iv; that 
of Caby,-subnitrate of bismuth, gr. xv; glycerin and mucilage of acacia, 
of each 5ijss; dried alum, gr. ij; water, 31; and last,-tannic acid, gr. iv; 
water, gi. 
Some instructions as to the mode of making urethral injections will not be 
out of place here. 
The glass syringe, though much in use, is not a desirable instrument, being 
liable to break and wound the urethra. The piston rarely works properly, 
allowing the fluid to pass back along its sides. Hard rubber is a much 
safer and better material, and always to be preferred for this object. The 
syringe should have a capacity of two or three drachms, and its nozzle 
should be perfectly smooth, well rounded, and not exceeding three-eighths 
of an inch in length. (Fig. 1266.) 
After filling the syringe with the liquid, turning the point upward and 
Fig. 1266. 
Hard rubber syringe. 
expelling the air, introduce the nozzle along the lower wall of the urethral 
orifice, holding the instrument between the thumb and middle finger of one 
hand, with the index finger resting against the piston, and, while the lips of 
the meatus are pressed lightly together with the finger of the other hand, 
force the contents of the syringe into the canal. 
The nozzle is now to be withdrawn, while the meatus is kept closed with 
the fingers, and the injection retained for three or four minutes, during which 
time the under surface of the urethra should be gently rubbed backward 
and forward with the fingers of the unoccupied hand, so as to distribute 
the fluid along the spongy part of the canal and to insure its contact with 
the entire surface of the corresponding portion of the mucous membrane. SPECIFIC URETHRITIS, OR GONORRHOEA. 
465 
Large injections are not necessary; indeed, they are liable to do harm by 
entering the bladder. The capacity of the spongy urethra does not exceed two 
drachms, and when more than this amount 
of fluid is employed, as is sometimes done, 
with a view to unfold the plications of the 
mucous membrane, so that no part shall 
escape medication, firm pressure should at 
the same time be applied with a finger to 
the canal behind the scrotum. Mr. Durham 
uses a syringe with a nozzle, which throws 
the stream forward as the piston is sent 
home. 
It is during this stage that the patient is 
frequently harassed with painful erections. 
The free use of alkaline drinks, with hot 
fomentations, the frequent immersion of the 
penis in hot water, an occasional dose of 
Dover's powder or of bromide of potas- 
sium, and light bed-covering, at the same time not allowing the urine to 
accumulate in the bladder, constitute the best means of preventing this 
complication. 
During the stage of declination, the diet of the patient ipay be improved. If 
he is in the habit of taking wine, a little claret may be allowed, and permission 
may be given to sit up a part of the day. Under this treatment the disease 
gradually improves, so that in the course of three or four weeks all traces 
of inflammation will have disappeared. Notwithstanding that the recovery 
may appear complete, the patient must be instructed on several points, other- 
wise he will have the mortification of seeing the discharge return. Exercise 
must be moderate. All long walks, heavy lifting, severe straining efforts, 
and sexual indulgence are to be avoided. All impure reading or lascivious 
thoughts, at any time degrading, are now particularly injurious; and all kinds 
of stimulants, except a little red wine, as well as highly-seasoned articles of 
food, are to be avoided. 
A weak injection of sulphate of zinc or acetate of lead, used once a day, 
and continued for one or two weeks after all external manifestations of the 
disease have disappeared, is also a precautionary measure of great value. 
Although in a large majority of cases local remedies are quite sufficient 
for the treatment of gonorrhoea, the cure is undoubtedly facilitated by the 
internal administration of certain articles of the materia medica, among 
which balsam of copaiba has long held a prominent rank and one which 
neither time nor experience has in the least diminished. 
This remedy is considered by many to be suited to every stage of the 
disease, an opinion in which I do not concur. It is only when the acute 
symptoms have begun to subside, or at a period consistent with the use of 
astringent injections, that I regard its employment as proper. Copaiba may 
be administered in different formulae. The most convenient, and, in private 
practice, the least objectionable, is in the form of capsules, each containing 
about ten minims of the copaiba. Two of these taken four or five times a 
day are usually well borne without disturbing the stomach. Or it may be 
administered in mixture, associated with an alkali and an anodyne. The 
following formula is one which I find answers a very good purpose: 
Fig.1267. 
Injecting the urethra. 
R Balsam. Copaibse, gv ; 
Muc. Acacias, §ij ; 
Liquoris Potassae, ; 
Syrupi Hyoscyami, giss; 
Aquae Menthae Pip., §ijss ; 
Tincturae Opii Camph., ; 
01. Gaultheriae, gtt. xv.-M. 
Sig.-Tablespoonful three times a day. 
vol. ii.-30 466 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Though the action of copaiba is a local one, affecting favorably the in- 
flamed mucous surface as it is passed in the urine, this salutary property is 
acquired while passing through the kidneys, as it has been conclusively 
demonstrated to be powerless to cure when injected directly into the urethra. 
This statement is corroborated by the history of a patient of Ricord's who 
suffered from gonorrhoea and who at the same time had a urethral fistula. 
Copaiba was given, and the man was directed to allow his water to pass 
through the abnormal opening. The disease disappeared in that part of the 
urethra which was behind the fistula, but continued in the remaining part 
of the canal. He was now ordered, by closing the accidental opening with 
his finger, to pass the urine entirely by the natural channel; after which 
the anterior part of the urethra was also cured. 
Copaiba is liable, when given too freely, eithei* to disturb the stomach or 
to develop a cutaneous rash which is attended with considerable heat and 
itching. The lattei- is a matter of no consequence; it neither detracts from 
the value of the remedy nor contra-indicates a continuance of its use, as the 
irritation of the skin is a temporary inconvenience, which disappears under 
the use of hot baths and a lotion of a weak solution of carbolic acid. 
The gastric symptoms are of more importance, and suggest either lessening 
the dose or the entire suspension of the remedy. 
Other articles, as cubebs and the oil of sandal-wood, possess unquestionable 
value in the treatment of gonorrhoea. Though much inferior to copaiba, 
they may be used with great advantage in cases where the latter develops 
gastric uneasiness. They can be given most conveniently inclosed in cap- 
sules of gelatin. 
A variety of gonorrhoea known as Conorrhcea sicca is described. I have 
never witnessed anything answering to this disease. It is represented as 
presenting the ordinary signs of urethral inflammation, viz., fullness, heat, 
and swelling of the organ, with scalding micturition, but unaccompanied by 
any discharge. 
Complications.-The complications which are liable to supervene in the 
progress of a case of gonorrhoea are chordee, follicular inflammation, bala- 
nitis, posthitis, prostatitis, inflammation of Cowper's glands, prostato-cystitis, 
retention of urine, hemorrhage, peri-urethral abscess, chancre, herpes prae- 
putialis, bubo, embolism of the dorsal vein, and epididymitis. 
Chordee is an exceedingly common accompaniment of gonorrhoea, occurring 
most frequently during the night: it is provoked either by lascivious dreams, 
by distention of the bladder, or by the warmth of the bed. It is during the 
severity of the inflammatory stage that these attacks are most distressing, 
often continuing for a long time without intermission. The cells of the 
spongy tissue become painfully turgescent, the penis being curved either 
downward or in a lateral direction, according as the inflammatory infiltra- 
tion occurs in the corpus spongiosum or in one of the corpora cavernosa, 
rendering the affected parts inextensible. 
Treatment.-To prevent chordee, the patient should be allowed the free 
use of alkaline diluents, with hot fomentations, or the frequent immersion of 
the penis in hot water, with an occasional dose of Dover's powder. The bed 
should be hard and the bedclothing light, and the water should not be allowed 
to accumulate in the bladder. If these precautionary measures prove in- 
adequate, they can be supplemented with great advantage by the use of 
suppositories of camphor, opium, and lupulin (camphor, grains iv; opium, 
grains ij ; lupulin, grains xv; oil of theobroma, q. s. ut ft. suppos.). One of 
these introduced at bedtime will greatly moderate, if not prevent, the attacks. 
An obstinate chordee is resolved with the least delay by plunging the penis 
into ice-water or surrounding it with an ice-bag. No attempt should be made 
to subjugate the rebellious organ by forcible bending or "breaking," as is 
sometimes practiced. The conquest is gained at too dear a price, as it is liable 
to be followed by severe hemorrhage into the structure of the cavernous or 
spongy bodies, with subsequent deformity, and stricture. SPECIFIC URETHRITIS, OR GONORRHOEA. 
467 
Follicular inflammation.-The urethral inflammation extending into the 
follicles of the canal may excite so much swelling at their orifices as to 
cause their temporary occlusion. The accumulation of the perverted secre- 
tion in the fundus of the glands, togethei* with a plastic infiltration around 
their circumference, gives rise to small hard nodules, which may be felt 
through the skin along the urethra. These little tumors pursue one of two 
courses: either their urethral orifices, after the subsidence of the inflam- 
mation, open and allow the contents of the glands to pass out, and the in- 
filtration is absorbed, or they provoke suppuration in the adjacent cellular 
tissue and discharge externally by ulceration. 
These enlargements may sometimes be resolved by applying freely tinc- 
ture of iodine externally; but, should this fail, an incision of the skin and an 
excision of the cyst may be required. There is very little danger of impli- 
cating the urethra, inasmuch as the internal orifice of the follicle is perma- 
nently closed. 
Balano-posthitis.-Gonorrhoeal inflammation of the urethra may extend to 
the glans penis and the inner lining of the prepuce, or an inflammation 
in these regions may exist altogether independent of the former, when it is 
called a balano-posthitis, or external gonorrhoea. These structures may be 
implicated separately, constituting a balanitis or a posthitis, according as the 
head of the penis or the foreskin is affected. If it were not that the mucous 
.membrane covering the glans penis is hardened by exposure and thereby 
rendered less impressible to the action of the virus, balanitis would doubtless, 
in most instances of the disease wThere no stricture of the prepuce exists, 
always precede or accompany the urethral inflammation. 
The existence of the disease is easily recognized by the itching, pain, red- 
ness and excoriation of the glans, the swollen state of the prepuce, and a 
copious irritating and offensive purulent discharge. 
When the foreskin cannot be retracted, the diagnosis is rendered less cer- 
tain ; though, if there is little ardor urinse, wfith much preputial swelling and 
no particular disposition to erections, a balano-posthitis may be inferred. 
Treatment.-Nothing will more expeditiously remove such a condition 
than an injection of nitrate of silver (nitrate of silver, grains xx; water, §j), 
thrown in with a syringe between the glans penis and the prepuce, after 
having previously washed out with warm water all the purulent and seba- 
ceous secretions. 
It is seldom necessary to repeat the injection, and, if so, the nitrate of 
silver can be substituted by either acetate of zinc or acetate of lead. 
Inflammation of Cowper's glands.- When the gonorrhoeal inflammation 
passes down to the deep part of the spongy urethra, it extends by continuity 
of structure into the ducts of one of Cowper's glands, rarely into both. A 
peri-glandular cellulitis is kindled, and considerable infiltration takes place in 
the cellular tissue external to the affected gland. This complication has 
been particularly described by Gubler in his paper on 11 Diseases of the 
Urinary Passages." 
A sense of fullness in the perineum, tenderness on pressure on one side of 
the raphe a short distance in front of the anus, and a circumscribed enlarge- 
ment the size of a cherry-stone, which may be discovered by passing the 
finger just within the external sphincter and pressing it upward and forward, 
are the symptoms which denote the occurrence of this affection. This swell- 
ing may pursue a course like that which has been described as affecting the 
follicles, undergoing either resolution or suppuration. 
Treatment.-If there are much tension and tenderness, the local abstrac- 
tion of blood, followed by hot fomentations and a gentle cathartic, will aid in 
establishing resolution. If, however, the affection manifests no amendment, 
it will probably terminate in the formation of abscess, an event which is 
announced by a diffused fullness, induration, and throbbing in the perineum, 
accompanied probably with a rigor. 
The presence of these phenomena indicates the necessity of poultices, to 468 
INJURIES AND DISEASES OF THE GEN ITO-URINARY ORGANS. 
favor an event which cannot be avoided. As the resistance offered by the 
deep triangular ligament and the middle perineal fascia opposes the passage 
of the inflammatory products towards the surface, an early incision is de- 
manded, that the tissues may be unloaded and the danger of urinary fistula 
averted. 
Prostato-cystitis.-When a gonorrhoea has been injudiciously managed, 
either by the premature use of injections or by abortive plans of treatment, 
or where there have been intemperate excesses on the part of the patient, 
the inflammation is liable to extend into the prostatic portion of the urethra 
and the adjacent part of the bladder. The extension of the disease to these 
portions of the urethra and bladder occasions a frequent desire to urinate, a 
burning pain along the entire course of the urethral canal during, and par- 
ticularly severe after, urination, and a constant sense of fullness deep in the 
perineum, as though some foreign body was lodged in the lower part of the 
rectum. The discharge in these cases is often greatly diminished. 
Treatment.-This should be decisive, otherwise a very troublesome chronic 
inflammation or an irritable state of the bladder may be left, from which the 
patient will ever after suffer. The recumbent position, with the hips ele- 
vated, must be rigorously enforced, and the perineum be freely leeched. To 
quiet the muscular walls of the bladder, suppositories of opium become invalu- 
able, and, to obtain their best effects, require to be used two or three times a 
day, aided by the use of hot hip-baths. The urine is to be maintained in a 
bland state by the free use of alkaline diluents. 
Retention of urine may have both a spasmodic and an inflammatory origin. 
When from the former cause, it comes on suddenly, is intermittent, the patient 
being able to pass his water one hour and the next unable, and is sometimes 
preceded by a degree of urethral irritability which causes an involuntary 
escape of urine. The hot hip-bath and an injection of laudanum and starch- 
water will afford the necessary relief, and only when these fail is it necessary 
to employ the catheter. Inflammatory retention requires the same manage- 
ment as prostato-cystitis. 
Hemorrhage is occasionally seen to follow a violent chordee, from the rup- 
ture of the small vessels of the canal, and is rarely profuse. When sufficiently 
free and protracted to cause uneasiness, it can be arrested by cold. Only 
when very obstinate will it be proper to introduce a catheter and employ 
pressure. 
Peri-urethral abscess.-Inflammation of the cellular tissue exterior to the 
urethra is very common in cases of gonorrhoea, but it generally disappears 
with the decline of the urethritis. When, however, the inflammatory action, 
in consequence of mismanagement or from intrinsic peculiarity in the tissues 
themselves, becomes intractable, it may terminate in suppuration. There are 
two situations where the accident is prone to occur,-at the navicular fossa 
and near the bulb of the spongy body. In the former locality the sign of 
the abscess is a hot, painful swelling at the fraenum praeputii. It may open 
externally or internally, and in the former case is liable to leave a suppurating 
pouch or sac difficult to be healed. 
When the abscess is located in the bulbous part of the corpus spongiosum, 
the pus, guided by the middle perineal fascia, will travel into the scrotum 
and perineum, and, if the nature of the trouble is not understood, may give 
rise to the most disastrous consequences. 
A wealthy lumberman from the northern part of Pennsylvania came to 
Philadelphia on business connected with his calling. He was a magnificent 
specimen of a stalwart woodsman. During his stay in the city, and after 
perhaps a too free indulgence in wine, he was induced, in company with some 
boon companions, to resort, for the first time in his life, to a disreputable 
house. Forty-eight hours after exposure the signs of urethritis began to 
appear, and very soon ripened into a violent gonorrhoea. The virulence 
which the disease assumed created alarm in the mind of his medical attend- 
ant, and I was asked to confer in the case. I first saw the patient on the SPECIFIC URETHRITIS, OR GONORRHOEA. 
469 
fourth or fifth day of the attack. The penis was enormously swollen and 
cedematous, the discharge thick and bloody, the perineum and scrotum tumid, 
tense, and full of pus. Severe rigors had been experienced, and the man was 
quite delirious, with extremely feeble and frequent pulse, a leaky skin, and 
all the signs of pysemic poisoning. His wife and family were immediately 
notified by telegraph of his extreme illness, and barely reached town in time 
to witness his death. 
In cases of peri-urethral abscess, when the preceding inflammation does 
not yield to antiphlogistic measures, early and free incisions are necessary 
to empty the tissues of inflammatory products and preserve them from de- 
struction. 
Chancre.-A chancre may be concealed either in the urethra or beneath 
a phimosed prepuce, and may, by the local irritation, scalding, discharge, and 
swelling, counterfeit both gonorrhoea and balano-posthitis; or both diseases 
may exist together. Division of the contracted prepuce will reveal the exact 
condition of the parts, and, if both are found to be present, each should 
receive specific treatment. 
Herpes prceputialis.-This appears as a crop of vesicles around the margin 
of the foreskin; after the vesicles rupture and their contents escape, there 
is apt to be left a chapped or excoriated state of the skin, which becomes 
incrusted with the discharges from the abraded surface. 
Bathing the parts in hot water and applying the oxide of zinc ointment, 
or dusting with calomel, constitute the means of relief. 
Bubo.-The inguinal lymphatic glands are liable to become enlarged in gon- 
orrhoea, either from the propagated lymphitis or from sympathy. The 
enlargement is generally on one side only, and does not often end in sup- 
puration. 
Rest and lotions of lead-water and laudanum are usually sufficient to dis- 
perse the swelling, and if the adenitis does not yield to such applications a 
blister will probably determine the resolution. 
When signs of suppuration appear, the process should be favored by poul- 
tices, and as soon as the abscess is matured it should be opened. 
Embolism of the dorsal vein of the penis, though extremely rare, has occurred. 
It is the result of phlebitis or of peri-venous inflammation. The existence of 
the affection may be discovered by the presence of a hard, tendei' cord under 
the skin in the line of the dorsal vein. As the mischief is done before it is 
likely to be detected, the cure may be left to natural processes. When the 
tenderness continues along the course of the obstructed vessel, indicating 
some lingering inflammation in the cellular tissue around the vein, a narrow 
strip of vesication over the sensitive point will be productive of relief. 
Epididymitis and orchitis are quite frequent complications of gonorrhoea, 
occurring in about thirteen per cent, of all cases of the disease. This affec- 
tion is rarely witnessed earlier than the second week, and is in most instances 
a sequel rather than a concomitant of gonorrhoea, induced by cold, venereal 
excesses, and intemperance, the inflammation of the canal not having been 
entirely eradicated. When it appears early in the progress of gonorrhoea, 
it can usually be referred to injections used prematurely or of too great 
strength. 
The statistics of Fournier, Le Fort, and De Castelnau all show that the 
disease is most frequently encountered about the end of the first month suc- 
ceeding the appearance of the urethritis. When the inflammation attacks 
the epididymis the discharge from the urethra frequently ceases, beginning 
again when the former is relieved. 
Though the inflammation begins in the epididymis, it frequently extends 
to the testicle. It is not to be supposed that the inflammation reaches the 
organ by being propagated along the long stretch of intermediate mucous 
membrane between the urethra and the gland. There is between individual 
members of the same system, though diverse in function, a common bond 
of sympathy, established through the distribution of nerves, by which one 470 
INJURIES AND DISEASES OF THE GENITOURINARY ORGANS. 
organ, even though far removed by space, may participate in, or be influ- 
enced by, the suffering of another. It is through this peculiar kind of 
kinship that we explain the occurrence of gonorrhoeal epididymitis. 
The treatment proper to the disease will be described under affections of 
the testes. 
Consequences of Gonorrhoea. 
In addition to the complications which have been noticed, gonorrhoea is not 
■(infrequently followed by gleet, ophthalmia, rheumatism, and irritable bladder. 
Gleet.-When the acute inflammation of a gonorrhoea has been badly 
managed, it is liable to degenerate into a chronic state, or into what is gener- 
ally known as gleet,-a condition which often taxes the patience and skill of 
the surgeon and occasions no small degree of mental anxiety on the part of 
the patient. 
In gleet the discharge is very small in quantity, noticed chiefly in the 
morning and evening, has a viscid, glairy, bluish, or slightly yellow appear- 
ance, glues the lips of the meatus together, and leaves a slight stain on the 
linen of the patient. 
Frequently the urethral discharge is so slight that it is made apparent only 
by pressing it from the deep parts of the penile urethra with the fingers, or 
only a single drop of mucus and pus may be found occupying the meatus, a 
condition sometimes described as pin-head gleet. 
Weeks may elapse without any external manifestation of the disease, yet 
the exhaustion of a long walk, the congestion attending coition, or indul- 
gence in wine or othei* stimulating drink will call into activity the latent 
inflammation and cause for a few days a considerable increase in the dis- 
charge. 
The structural alterations which cause and perpetuate gleet are fourfold : 
first, it may depend on one or more spots of congested or chronically in- 
flamed mucous membrane, in which condition there is usually some sign of 
submucous thickening, or, secondly, on the presence of one or more patches 
of granulation-tissue, in most respects like those which are seen on the inner 
surface of the eyelids in certain forms of conjunctivitis; thirdly, it may arise 
from inflammatory thickening, as in stricture; and, fourthly, it may be the 
result of a chronic folliculitis. 
The portions of the urethra which are generally implicated in gleet are 
the fossa navicularis and the deep portion near the bulb of the corpus spon- 
giosum. There is some difference of opinion in regard to the contagious 
property of the discharge, some alleging that it is entirely innocuous and in- 
communicable when applied to the mucous membrane of the genital organs. 
This is unquestionably erroneous: so long as an individual labors under any 
discharge, however slight, which contains pus, he is liable to communicate 
a gonorrheal urethritis in coition. 
Treatment.-Before commencing to treat a patient for gleet, a very careful 
examination should be made into both the history of the case and the actual 
appearance of the discharge. 
Not a few persons allow themselves to be victimized by their own igno- 
rance, or by the ignorance and unprincipled representations of charlatans. 
It is quite common for young men to apply for relief when only a little 
glairy mucus is discovered in the orifice of the urethra, and this present only 
when there has existed some previous sexual excitement,-a condition which 
merely indicates a temporary physiological activity of the follicles of the 
mueous membrane of the urethra, and which is entirely natural and con- 
sistent with a healthy condition of the canal. 
Other persons, peculiarly sensitive and apprehensive, after having bad an 
attack of gonorrhoea, notwithstanding that the disease may have been treated 
with unexceptionable skill, are constantly "milking" the penis to see if some 
trace of the discharge may not be discovered. This very common practice 
seldom fails to supply what is so officiously sought after. The same manipu- CONSEQUENCES OF GONORRHOEA. 
471 
lation will rarely fail to excite a flow of the ordinary mucous secretion in the 
urethra of one who has never suffered from gonorrhoea. Besides, it must not 
be forgotten that for some time after an attack of the disease has passed 
away the mucous membrane remains in a supersensitive state and intolerant 
of such violence as this rude handling must inflict. 
Again, there are delicate, pale, lymphatic young men, who, from an im- 
poverished condition of the blood and a general state of relaxation, may be 
annoyed by a thin mucous discharge long after a gonorrhoea has disappeared, 
or even when no disease of the kind has existed. 
The foregoing considerations are consequently quite important to the 
proper understanding of the true nature of urethral discharges, and in such 
cases a few words of explanation and friendly counsel will allay the ground- 
less apprehensions of the patient and restore his peace of mind and use- 
fulness. 
The next important point is to ascertain the morbid condition on which 
a gleety discharge depends, and for this purpose it is necessary to make an 
exploration of the urethra. If the discharge is an old one, there will be 
reason to suspect the presence of stricture; and this must be determined by 
passing along the canal a soft bougie having a bulbous extremity. 
If the subject of stricture is eliminated from the diagnosis, or if the gleet 
is of recent standing, it will most probably depend on a localized congestion 
of some spot at the anterior or posterior point of the penile portion of the 
urethra, which may be detected by passing slowly along the canal a good- 
sized metallic bougie. Contact of the instrument with such a patch will extort 
some expression of pain or uneasiness from the patient, and the diagnosis 
will receive further confirmation if, by external pressure over the suspected 
spot with the fingers while the bougie remains in the canal, tenderness is 
found to exist. 
Granular urethritis seldom occurs as a recent lesion. It is, however, almost 
always present when the disease has existed for three or four months, and 
is, I believe, a more common cause of gleet than is stricture. The endoscope 
has been employed to ascertain both the seat and the nature of the cause 
keeping up the discharge, and also for the purpose of applying remedies 
directly to the spot; but in my hands the instrument has proved exceed- 
ingly unsatisfactory. 
Treatment.-When the suspicion of stricture has been verified by a phys- 
ical exploration, its treatment must take precedence of all other measures; 
and when this has been brought successfully to a termination, the gleet usually 
disappears. 
When the case depends on one or more spots of local congestion, it may 
frequently be cured by deep injections, preserving the urine in an alkaline 
state, avoiding stimulants and sexual intercourse, and toning up the general 
system if there is evidence of weakness or enfeebled health. The injections 
as they are often employed are prejudicial, on account of their strength and 
the manner in which they are used. It is imagined that, inasmuch as the 
disease is a chronic one, they should be strong and frequently changed. As 
they are introduced into the canal in the ordinary manner, the entire mucous 
surface, sound as well as diseased, is subjected to unnecessary irritation, and 
frequently the injections do not reach the affected part of the urethra at all. 
The substances which may be employed with the greatest advantage as in- 
jections are sulphate of zinc, acetate of lead, nitrate of silver, persulphate of 
iron, permanganate of potash, and the compound solution of iodine. The 
first two agents rarely require to be used stronger than in the proportion of 
two or three grains to the ounce of water, and the third not exceeding two 
grains to the ounce of water. The formula for the persulphate of iron and 
the permanganate of potash is half a drachm of either to six ounces of water, 
and for the iodine, five or ten drops to the ounce. Once a day is sufficiently 
often to use such injections. 
Alkalinity of the urine must be maintained by the daily use of diluents 472 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
containing bicarbonate of soda or of potash. The internal exhibition of 
balsam copaibse is not contra-indicated in gleet, but, on the contrary, is highly 
advantageous so long as no gastric distress occurs. I believe that in this affec- 
tion, as well as in acute gonorrhoea, this article possesses properties which 
render it preferable to either cubebs or yellow oil of sandal-wood. 
If, after two or three weeks have elapsed, no progress has been made to- 
wards the cure of the disease, it will be proper to resort to deep injections; 
and these should be made preferably by the surgeon himself. The instrument 
for the purpose is a syringe holding one drachm, and having a long, very 
slightly curved nozzle with a number of very small openings near its free 
extremity. (Fig. 1268.) After charging the instrument with a solution of 
Fig. 1268. 
Syringe for deep urethral injections. 
nitrate of silver (grains ij of the salt, §i of distilled water), the long canula- 
point is cautiously passed down almost to the termination of the penile 
urethra, and its contents gently discharged into this portion of the canal, a 
finger being at the same time pressed immediately behind the scrotum and 
there held for two or three minutes after the withdrawal of the syringe, in 
order that the fluid may be retained in this part of the tube until the mucous 
surface has been thoroughly medicated. 
When this has been effected, and without removing the post-scrotal press- 
ure, an ordinary penis syringe filled with warm salt water or flaxseed-tea 
must be discharged into the urethra, when the fingers may be taken away 
and the liquids allowed to run out together. 
In this way the affected surface may be treated with a strong solution of 
nitrate of silver and the rest of the mucous membrane at the same time 
receive protection by the dilution effected by the second injection. This pro- 
cedure may be repeated two or three times a week. Blistering the external 
surface of the urethra has been extolled by Milton; and when the gleet de- 
pends on inflammation in the urethral lacuna), and the vesication is repeated, 
it certainly does exert no small influence in eradicating the disease. Pro- 
fessor Gross advises, in similar cases, the use of tincture of iodine frequently 
brushed along the under surface of the penis. 
When the patient's general health is below the proper standard, the local 
conditions will be greatly benefited by constitutional remedies, such as tinc- 
ture of sesquichloride of iron, quinine, extract of malt, cod-liver oil, red wine, 
moderate exercise in the open air, and sea-bathing. 
Granular gleet is the most incorrigible and provokingly obstinate of all 
forms of the disease. It is useless to speak of dealing tenderly with so stub- 
born an affection. Whether the granulations are few or many, the topical 
applications must be potent,-nitrate of silver or sulphate of copper being 
among the best, and of a strength of not less than sixty to one hundred 
grains to the ounce of distilled water. 
There are several ways of applying these remedies. I employ very fre- 
quently an instrument which consists of a straight tube with a closed and 
rounded extremity near which are two elongated fenestra). In this tube 
runs a stylet or porte-caustic charged with the solid nitrate of silver. (Fig. 
1269.) 
To make the application, the instrument is passed down the urethra, press- 
ure being made on the outside with a finger until the diseased surface can CONSEQUENCES OF GONORRHOEA. 
473 
be located by the uneasiness experienced by the patient, when, by turning the 
stylet bearing the caustic, the latter is brought opposite the fenestra. If the 
instrument is now turned in the urethra, the granulations can be cauterized, 
after which, by reversing the movement of the stylet, the instrument may be 
withdrawn without touching any other part of the canal. 
Fig. 1269. 
A less decided impression may also be made by a dossil of absorbent cotton 
attached to a stylet and concealed within a hollow, catheter-shaped tube. 
(Fig. 1270.) 
Instrument for local cauterization of the urethra. 
Fig. 1270. 
This will allow of a direct application to the affected surface without touch- 
ing other portions of the canal. The instrument is carried along the urethra 
until the offending point is reached, when the cotton, previously saturated 
with the liquid, is pushed forward and turned round by the stylet two or 
three times, thus cauterizing the diseased surface, when it is again drawn 
into the tube and the latter removed from the canal. 
A second plan is by introducing an ordinary endoscopic tube, bearing an 
obturator to admit of its harmless admission, and, after reaching what is 
believed to be the diseased point, removing the obturator and touching the 
part with a dossil of cotton attached to a long wire or probe: this may be 
repeated twice a week for four or five applications, after which the usual 
weak injections may suffice to complete the cure. 
It is in such cases that the endoscope has been lauded, particularly by De- 
sormeaux, as being peculiarly useful in disclosing the granulated or diseased 
surface and offering a convenient medium for local medication. I must con- 
fess that, after considerable practice in the use of the instrument, I have 
never been able satisfactorily to distinguish between the diseased and the 
healthy urethra. The mucous membrane which appears at the end of the 
tube in a few moments becomes congested by crowding against the margin 
of the instrument. It is possible, however, that my failure is due to the 
absence of that deft manipulation which belongs to thS distinguished inventor 
of this ingenious mechanism. 
A third method of cauterizing the granulations, when the latter are be- 
lieved to be widely disseminated, is, after introducing the long probe contain- 
ing the cotton charged with nitrate of silver through the tube, to remove 
the latter, letting the little swab remain, which may then be withdrawn, in 
doing which no part of the mucous membrane will escape being cauterized. 
It is rarely necessary to resort to so heroic a plan of treatment, and, when 
so, the redundant caustic should be immediately neutralized by an injection 
of a weak solution of salt and water. 
Instrument for cauterizing limited districts of the urethra. 474 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
The introduction of sounds, plain or medicated with various ointments, is 
frequently practiced. As ordinarily employed, they are capable of doing little 
else than harm, by irritating the surface of the urethra; but, used in the 
manner I shall direct, they are very important adjuvants in the treatment of 
granular gleet. The instrument, which should be a metallic one and in size 
almost equal to the full capacity of the canal, should be carried through the 
penile urethra, and there retained for an hour, if the patient can endure its 
presence. The operation may be repeated three or four times a week. It 
acts much in the same way as strapping does in repressing the redundant 
granulations of an ulcer and favoring cicatrization. 
Various medicated bougies have been devised, by diffusing astringents, such 
as zinc, tannin, lead, copper, and other substances, through a solution of gum 
tragacanth, and allowing it to harden in moulds. These are introduced into 
the urethra and allowed to dissolve slowly in the canal. I have not been 
favorably impressed with their use. 
Gonorrhceal Ophthalmia begins as a conjunctivitis, the result most prob- 
ably of inoculation by the purulent matter coming in contact with the 
palpebral or ocular conjunctiva. It is a formidable malady, and frequently 
results in complete disorganization of the eye and loss of vision. Hence 
the importance of communicating to patients suffering from gonorrhoea the 
necessity of observing the utmost care and cleanliness, and of always washing 
the hands after handling the penis. The subject will be treated of under the 
head of diseases of the eye. 
Gonorrhoeal Rheumatism.-This affection, fi/st noticed coincidently by 
Selle and Swediaur almost a century ago, makes its appearance generally 
during the acute stage of gonorrhoea, though it may occur at a later date. 
Women are singularly exempt from the disease. Its invasion is usually sud- 
den, and it may either select the synovial membrane of the joints, preferably 
the knee, elbow, or ankle, or may expend its violence on the fibrous and 
bursal structures. In the latter form, resembling in its behavior ordinary 
rheumatic inflammation, several joints may be simultaneously attacked; the 
muscles and their tendons, the sheaths through which they pass, the bursal 
sacs, and the nerves also suffer. Even the sclerotic coat of the eye, and the 
iris, may become involved. When gonorrhoeal rheumatism attacks the 
synovial membrane of a joint, though there may be little pain and an entire 
absence of surface redness, there will generally be a considerable effusion into 
the cavity of the articulation, which is removed with no small difficulty. 
When more widely distributed, affecting several joints at the same time, or 
the contiguous muscles with their tendons, the tenderness and pain equal in 
severity those of ordinary acute rheumatism, and are attended in most in- 
stances by some fever, which, however, is transient, rarely lasting over five 
or six days. The subsidence of the constitutional disturbance does not 
appear to affect the local symptoms in any way, the suffering continuing 
about the same, or perhaps being even increased in severity. 
Little is known of the true nature of the disease. The doctrine of metas- 
tasis receives little or no support from the urethral conditions, as the appear- 
ance of the rheumatism is neither preceded nor followed by any diminution 
in the amount of the discharge or by any visible alteration in its quality. 
Nor is the supposition of a previous rheumatic diathesis entitled to any higher 
consideration. In a number of cases which I have seen, no such connection 
could be traced; on the contrary, the patients were all quite young, with 
a single exception, and had been remarkably free from muscular pains or 
stiffness of the joints. The most plausible theory is the septicoemic, according 
to which there are introduced into the circulation certain poisonous matters 
which give rise to the general and local disturbance. 
Between ordinary rheumatism and that arising from gonorrhceal causes 
there are several notable differences, which prove a difference in origin of 
the two affections. They may be contrasted as follows: NEURALGIA OF THE URETHRA. 
475 
GONORRHtEAL RHEUMATISM. 
Previous existence of a purulent urethral dis- 
charge. 
Constitutional disturbance transient, and never 
very acute. 
Fixed, with little tendency to change its lo- 
cality. 
Females rarely, if ever, affected. 
Tendency to become multilocated not marked. 
Little tendency to cardiac complications. 
COMMON RHEUMATISM. 
No urethral discharge. 
Constitutional disturbance often severe and 
prolonged. 
Frequently shifting from joint to joint. 
Females suffering with almost the same fre- 
quency as males. 
Several joints frequently attacked at the same 
time. 
Marked tendency to cardiac complications. 
With regard to the last differential peculiarity, that of cardiac complica- 
tion, La Cassagne and one or two other writers speak of endocarditis follow- 
ing an attack of gonorrhoea; but their experience does not accord with that 
of the majority of observers. 
Treatment.-The disease, as a rule, yields very slowly and reluctantly to 
treatment. If it assumes the articular form, the joint must be placed in a 
state of perfect rest, and, if very tender and painful, a few leeches should be 
applied. In the absence of leeches, or even after their use, blistering the 
surface of the articulation will be productive of decided relief. As soon as 
the tenderness has somewhat abated, pressure should be applied with an 
accurately-adjusted roller. The bowels are to be kept open, and the kidneys 
should be acted upon by diuretics, such as acetate or nitrate of potash, while 
rest is to be procured by the occasional use of Dover's powder. When the 
disease involves the muscular and fibrous structures, iodide of potassium will 
afford some relief, assisted by frictions with anodyne liniments. In case the 
eye becomes affected, small doses of bichloride of mercury should be asso- 
ciated with the iodide of potassium, a blister should be applied to the temple, 
and the iris should be protected by the local use of atropia. The local 
treatment of the gonorrhoea must not be suspended while that for the rheu- 
matism is being carried on, but should be conducted without any reference 
to the latter. 
Irritable Bladder is one of those sequels of gonorrhoea which follow cases 
in which the prostate or the neck of the bladder has participated in the 
inflammation. It may continue for a long time and prove to be a very 
troublesome condition. 
The patient is harassed with a frequent desire to micturate, and compelled 
to empty the viscus many times during the day and night, in some instances 
every half-hour. The urine remains perfectly clear, though, when the irrita- 
bility is not relieved, it finally becomes cloudy. Severe and painful vesical 
tenesmus following each micturition is not an uncommon accompaniment of 
the affection. There is often a neuralgic element present, which aggravates 
the patient's distress. 
Treatment.-As long as there is no muco-purulent deposit in the urine 
the case may be regarded as purely one of irritation, uncomplicated by in- 
flammation. Alkaline diluents must be prescribed, with anodyne supposi- 
tories, and the use of the cold hip-bath. Quinine and extract of hyoscyamus 
will also prove useful; and the patient must be urged to pursue a systematic 
method of urinating, to resist the inclination to empty the bladder, and, by 
thus gradually prolonging the periods between the micturitions, to acquire a 
voluntary control over the viscus. The diet must be of the most unirritating 
character, though nutritious, and all stimulants should be forbidden. 
Neuralgia of the Urethra. 
Neuralgia of the urethra cannot be considered by any means common as 
an idiopathic affection of the urethra, though it frequently exists secondarily 
to some prostatic, vesical, or renal irritation, as the presence of a calculus in 
lithiasis and oxaluria, or a congested state of the prostate body. 476 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
It is often witnessed in connection with anal fissure, both in the male and 
in the female, and in the latter may be connected with some disturbance of 
the menstrual function. When the neuralgia cannot be traced to some one of 
these causes, it is most probably referable to masturbation, sexual excess, or 
miasmatic influence. No period of life confers exemption from the disease, 
though it is most common in the young. The attacks are usually sudden, 
though sometimes preceded by a sense of weight or fullness of the penis. 
The pain is darting, intermittent, and may extend beyond the limits of the 
urethra, shooting up to the bladder, the rectum, and even along the inside of 
the thighs. Seldom does it continue for any length of time without creating 
the desire to urinate, followed by more or less burning or scalding sensations 
along the whole length of the urethra. The attacks go and come at uncertain 
intervals, or they may recur with considerable regularity. 
Treatment.-The treatment must be based on an intelligent understand- 
ing of the cause, and, when this can be discovered, its removal must be the 
first step towards effecting a cure. If a foreign body is detected in the 
urethra or in the bladder, it must be removed. If the disease results from 
some vice in the urinary secretion, that will demand correction. If it pro- 
ceeds from fissure of the anus, the division of the muscle will be required. 
When there is reason to believe that it has a uterine origin, remedies ad- 
dressed to that organ will be necessary; and if from sexual excesses, ab- 
stinence must be enjoined. 
The remedies which promise a cure in uncomplicated cases of urethral 
neuralgia are quinine and arsenic, administered in full doses, and, if the pa- 
tient is at all reduced in general strength, iron, the cold hip-bath, flagella- 
tion of the hips, a chaste life, and out-door exercise will materially aid in 
removing the disease. When it is miasmatic in its origin, full doses of quinia, 
with piperine, constitute the most efficient remedies. To shorten or alleviate 
the suffering during an attack, hot hip-baths and suppositories of opium 
should be ordered. 
Stricture of the Urethra. 
By stricture of the urethra is understood a permanent loss of the dilata- 
bility of the urethral canal, in consequence of inflammatory alterations in 
its structure. These alterations, whereby the urethral canal is so narrowed 
as to offer an obstacle to the passage of instruments and to the escape of urine, 
may have either a traumatic or an idiopathic origin. The traumatic form of 
the disease is produced either by internal or by external violence. As illus- 
trative of this point may be mentioned the improper or rude use of bougies, 
catheters, or other instruments, and the introduction of foreign substances, 
either from without or from the bladder. Examples of external violence are 
falls upon the perineum, kicks, and shot wounds received on the under sur- 
face of the organ. By far the most common causes of stricture are gonor- 
rhoeal urethritis and the injudicious employment of injections. 
During the late American war there were reported 2581 cases of stricture 
of the urethra. The records also show that there were among the white and 
colored troops 102,893 cases of gonorrhoea. Considering the infrequency of 
shot wounds of the penis, a very small number of these strictures must have 
had a traumatic origin, so that it is fair to infer that an overwhelming pro- 
portion may be justly placed to the credit of venereal disease. The less 
common causes of urethral stricture are sexual excess, masturbation, and 
chancre. 
Spasmodic stricture, which is retained by some writers as one of the divisions 
of this disease, is only a temporary and incidental narrowing of a section of 
the canal, the result of muscular spasm from a pre-existing local irritation, 
and should not be admitted as one of the forms of this affection. The same 
may be alleged of the so-termed inflammatory stricture, in which there is a 
temporary swollen state of the mucous membrane of the urethra, notably STRICTURE OF THE URETHRA. 
477 
that of the prostatic portion, and which subsides in a short time, leaving the 
tissues as sound as before its occurrence. 
Stricture of the urethra is almost exclusively a disease of the male, a sexual 
distinction which is due to the length and the exposed situation of the canal, 
and to its relation to a large amount of erectile tissue, by which it is rendered 
liable to injury and to inflammatory changes. 
Position of strictures.-Any portion of the urethra, except the prostatic, 
may be the seat of stricture; but there are certain tracts in the course of the 
canal which are more frequently affected than others, as the last half-inch of 
the penile urethra, the anterior half of the membranous portion, the first inch 
posterior to the external orifice, and the middle of the canal. Very careful 
observations have been made by Sir Henry Thompson, Professor Otis, and 
Hr. S. W. Gross, and the results of the labors of these different gentlemen 
vary somewhat as to the relative frequency of coarctation in the specially 
vulnerable parts of the canal. For example, Sir Henry Thompson examined 
270 preparations, or 320 strictures, among the pathological collections in Great 
Britain and on the Continent. Of this number, 215 were found at the termi- 
nation of the spongy and in the commencement of the membranous portions 
of the urethra (67 per cent, of the entire number); 54, or 17 per cent., at 
the anterior extremity; and 51, or 16 per cent., at the middle of the spongy 
urethra. Professor Otis, whose observations were made on living subjects, 
found 258 strictures in 100 persons: 163, or 63 per cent., occupying the an- 
terior portion of the canal; 81, or 31 per cent., the middle; and 14, or only 
5 per cent., the membranous portion. Dr. S. W. Gross found, in examining 
100 living persons, 173 strictures: 76, or 43.93 per cent., located in the pos- 
terior region; 48, or 27.74 per cent., in the middle region; and 49, or 28.32 
per cent., in the anterior region. A very large proportion of all the stric- 
tures which have come under my observation, both in private and in hospital 
practice, have been seated in the terminal portion of the spongy and in the 
front part of the membranous urethra. 
Strictures are either solitary or multiple, the former being much the more 
frequent. In multiple stricture I have rarely witnessed more than four, 
though instances are recorded of six, eight, and eleven, and in one case men- 
tioned by Professor Otis there were fourteen. It is asserted that anterior 
strictures are rarely single, and that the presence of one in this part of the 
urethra betokens a similar coarctation in the posterior portion of the canal, 
-an observation which my own experience amply verifies. 
Strictures are rarely met with in persons under twenty-five years of age, 
unless as a result of traumatism. Professor Ashhurst met with a case of fatal 
urinary extravasation, from the urethra giving way behind a close stricture, 
in a lad eleven years of age. I successfully performed perineal section for 
the cure of urethral fistula following stricture in a boy of fourteen in the 
Pennsylvania Hospital. 
Classification.-Seizing on some peculiarity in sensibility, degree, physical 
quality, origin, age, resistance, or form, writers have constructed a classifica- 
tion as formidable to contemplate as it is useless in practice. Thus, we have 
irritable stricture, partial and complete, soft and callous, elastic and non- 
elastic, traumatic and idiopathic, recent and old, permeable and impermeable, 
linear, annular, regular, and bridle strictures, together with many others of 
less imposing designations. In almost all urethral coarctations of the nature 
of true stricture the obstruction consists either of false bands stretching 
across the canal, or of plastic deposits in the submucous cellular tissue, 
causing circumferential induration; or both conditions may exist together. 
Accordingly, a very simple division of the subject is into the membranous, 
indurated, and mixed strictures. 
In the first, or membranous variety, the band may be a single crescent- 
shaped membranous fold, limited to one side of the canal, or it may encircle 
the latter, forming a circular valve with a central opening, which has been 
not inaptly compared to the pyloric orifice of the stomach; or the bands may 478 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
be multiple and intersecting, giving a reticulated appearance to the affected 
portion of the urethra. A third variety is occasionally met with, in which 
there appear in the urethra a series of fan-like plications radiating from a 
central white scar. 
In the second variety, the induration which constitutes a dominant fea- 
ture of the stricture may be limited to the cellular and muscular tissue im- 
mediately underlying the mucous 
membrane of the canal, or it may 
include, when seated in the spongy 
urethra, the erectile tissue, and, in 
some old, incorrigible cases of the 
disease, even the fibrous membrane 
of the corpus spongiosum. The cir- 
cular disposition of the induration 
forms the annular stricture of the 
urethra. 
In the mixed form, the charac- 
teristics of both the membranous 
and the indurated stricture are 
found conjoined. Examples of the 
two varieties of stricture are rep- 
resented in Figs. 1271 and 1272. 
Pathology.-Though the exist- 
ence of urethral stricture was well 
known to the ancient body of phy- 
sicians, they were entirely ignorant 
of the nature of the anatomical 
changes which occasioned the ob- 
structions. About the lattei' part 
of the seventeenth and the begin- 
ning of the eighteenth century 
the subject began particularly to 
attract the attention of writers, 
among whom were Pietre, Ledran, Goulard, Arnaud, and several others, and, 
still later, John Hunter, Sir Everard Home, Desault, and, more especially, 
Benjamin Bell. 
In idiopathic stricture the initial step in the formation of the disease is a 
localized chronic urethritis. After the acute inflammation of the mucous mem- 
brane of the canal has disappeared, there remains at some point in the course 
of the chronically-inflamed urethra a patch, which, under the irritating influ- 
ence of the urine and the repeated congestions attending erections and sexual 
indulgence, continues to linger without particularly attracting the notice of 
the patient,-it may be, without his knowledge at all. Often the only evi- 
dence of there being anything wrong in the canal is the existence of a gleet. 
This local inflammation is accompanied by a submucous infiltration of cell- 
forms and plastic lymph. These cells, partly emigrants and partly derived 
from the anatomical components of the parts, become gradually transformed 
into connective tissue, on the amount and maturity of which depends the sur- 
rounding induration. During the progress of this submucous new formation 
all distinction of tissue is frequently lost, the mucous membrane and the cel- 
lular and muscular structures all becoming blended into an indistinguishable 
mass of connective tissue, having marked cicatricial properties, and seriously 
diminishing the elastic and voluntary contractility of the canal, in con- 
sequence of which the last drops of urine are not promptly expelled. When 
granulations have existed, a more or less gleety discharge will always be 
present: indeed, a granular condition of the urethra is regarded by Desor- 
meaux as an invariable antecedent and accompaniment of stricture,-an 
opinion, however, in which I do not concur. There are many cases of 
stricture in which not a trace of discharge has been noticed from the time 
Fig. 1272. 
Fig. 1271. 
Membranous stricture. 
Indurated stricture. STRICTURE OF THE URETHRA. 
479 
the gonorrhoeal inflammation disappeared until some difficulty in micturition 
was observed, a period often of several years. 
A stricture once formed is constantly liable to acute attacks, which are 
accompanied by additional accumulations of new inflammatory products, and 
these in turn undergoing organization enlarge the sphere of induration, en- 
croaching more and more on the lumen of the canal and correspondingly 
detracting from its dilatability. 
Symptoms.-Among the earliest signs of urethral stricture are the pres- 
ence of a slight discharge from the urethra and some trouble experienced in 
micturition. 
The amount and character of the discharge are subject to great variations. 
It may not exceed a single drop, gluing together the sides of the meatus, 
or it may be sufficiently free to lead to the suspicion that gonorrhoea has 
been again contracted. In other instances the only evidence of anything 
abnormal is the presence in the urine of little shreds of mucus. 
The inconvenience experienced in urination consists in increased frequency 
of micturition, the bladder being emptied at short intervals through the day, 
and frequently during the night. The stream is diminished in size, force, 
and velocity, and, as it lessens, the power to expel it with vigor is corre- 
spondingly lost; as the obstruction increases, it becomes small, forked, twisted, 
or divided into several small branches, until finally it may end in dribbling, 
or escape only in drops, requiring for its expulsion severe straining, followed 
by smarting and pain. Frequently the patient is obliged to stand for some 
time making ineffectual efforts to relieve the bladder, and is compelled to 
wait for a still longer period in order to discharge the last drops from the 
canal. In aggravated cases, the forcible efforts which are necessary to 
empty the bladder are liable to produce hemorrhoids, hernia, and prolapsus of 
the rectum, and with the latter, not unfrequently, the escape of fecal matter. 
Pain and uneasiness are also experienced in the perineum, through the 
testicles, in the groins, and around the hips. The constant irritation occa- 
sioned by the mechanical occlusion of the urethra, with the concomitant 
difficulty in micturition, keeps the penis often in a state of passive congestion, 
provoking painful erections and nocturnal emissions. The same obstacle 
which prevents the flow of the urine resists the escape of the semen, and 
consequently the sufferer is annoyed with the slow escape of the secretion 
during the day. The urine, after a time, becomes altered in appearance, 
partly from the local irritation at the seat of the stricture being propagated 
to the bladder, and partly from the inability completely to discharge the con- 
tents of the viscus. The residual urine undergoes decomposition and reacts 
on the mucous membrane, in consequence of which the water becomes alka- 
line, cloudy, and ammoniacal, depositing, after standing for some time in 
a vessel and cooling, a heavy precipitate consisting of the triple phosphate 
of magnesia and ammonia, together with a ropy muco-pus and vesical 
epithelium. In addition to these symptoms there may follow irritation or 
incontinence of the urine. It can be readily conceived that where the lumen 
of the urethra has -been greatly diminished and the parts rendered exceed- 
ingly irritable the canal would on slight provocation, occasioned by alter- 
ation in the constitution of the urine or by exposure to atmospheric vicis- 
situdes, giving rise to inflammatory or congestive swelling, become so tightly 
closed as entirely to prevent the escape of urine, and culminate in retention. 
It is at such time also that incontinence may arise, the latter being related 
to the former as effect to cause. This incontinence, which is so often spoken 
of as paralysis, is due either to an over-distended bladder or to so great 
obstruction that the column of water issuing from the bladder and not being 
able to escape, except in drops, keeps the neck of the viscus so dilated as to 
make the action of the sphincter nugatory, and hence the constant drib- 
bling which renders the patient's clothing, bed, and person wet and offensive 
from the urinous odor. 
Diagnosis.-Though the symptoms enumerated, collectively considered, 480 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
are sufficient to determine the existence of urethral stricture, the diagnosis 
may be placed beyond all possibility of error by a physical exploration of 
the canal. This examination can be conducted with either a metal or a 
soft bougie. For safety, simplicity, and accuracy the soft bulbous bougie of 
Leroy d'EtiolIes, or the metallic one of Otis, is to be preferred. These in- 
struments have an acorn or olive-shaped bulb attached to a long, flexible shaft. 
(Figs. 1273, 1274.) Their sizes answer to the number of the scale in ordinary 
use. 
Fig. 1273. 
Metallic bulbous bougie. 
Fig. 1274. 
Soft bulbous bougie of Leroy d'EtiolIes. 
Before commencing with the exploration, it is a good rule to have the 
patient urinate. Some estimate of the degree of obstruction may be formed 
from the size of the stream, and an instrument selected accordingly. It is 
well to commence with the larger and proceed to the smaller-sized bou- 
gies. Selecting one which is deemed of the proper dimensions, it should be 
oiled, introduced into the orifice of the urethra, and slowly pushed down 
to the canal until it encounters a positive obstruction. A mark must now 
be made with the finger-nail on the shaft of the instrument at the meatus, 
when the bougie can be withdrawn and the distance between its bulb and 
the mark on the stem measured, which will indicate the distance of the stric- 
ture from the orifice of the urethra. This determined, a smaller instrument 
should be selected, one which can be passed through the coarctated portion of 
the canal and carried onward into the bladder, thus detecting other strictures 
in its passage if any such exist. The next step is to ascertain the length of 
the obstruction. In acquiring this information, the bougie, now supposed to 
be in the bladder, is slowly withdrawn. When the base of the bulb comes 
in contact with the deep extremity of the stricture it will be momentarily 
arrested, whereupon a mark should be made on the shaft. Increasing the trac- 
tion, the contracted portion of the urethra will be distinctly felt by the resist- 
ance offered to the progress of the instrument, which suddenly ceases as soon 
as the bulb has passed the limits of the stricture, which it does with a distinct 
hitch. If a second mark is now made on the shaft of the bougie, the dis- 
tance between the two gives the length of the coarctated portion of the canal. 
In connection with the use of the bulbous bougie there is one important fact 
noticed by Dr. J. William White, of Philadelphia, and demonstrated by him 
in one hundred examinations of healthy urethras at the University Hospital, 
and by a series of dissections in the dead-room of the Philadelphia Hospital. 
There is almost invariably a point in the normal urethra in passing which 
during the withdrawal of a bulbous bougie the sensation imparted to the 
hand of the surgeon is precisely similar to that experienced in passing a 
stricture and is therefore liable to be misinterpreted. This point is situated 
in the membranous urethra just where it is invested by the posterior layer 
of the deep perineal fascia; and the arrest of the bougie during withdrawal 
is occasioned, as was shown by Dr. White, by the hitching of the base of the 
bulb on this fascia as the instrument passes from the movable prostatic 
urethra to the more fixed membranous portion. 
In the absence of the bulbous instrument the ordinary soft or metallic STRICTURE OF THE URETHRA. 
481 
bougie can be used in working out the diagnosis of stricture; and in making 
a selection of the proper number for testing the state of the canal, it is always 
proper to descend the scale, and not to ascend it, beginning, say, with a No. 
18 and then proceeding to those of a smaller size as the case may require. 
If the meatus is abnormally small, it should be increased in order to allow 
the passage of a proper-sized bulb. If, after repeated trials, in which the point 
of the bougie is made to follow different sides of the urethra, the instrument 
is found to be arrested at the same point, and especially if there is realized a 
rough sensation, the existence of stricture may be positively affirmed. The 
endoscope has been employed as a means of diagnosing the presence of stric- 
ture, but little assistance can be expected from its use. 
For a long time there may be very slight, if any, constitutional disturbance, 
except, perhaps, when an attack of retention comes on from exposure, when 
there may occur a brisk chill, followed by fever, hot skin, high temperature, 
and headache, which, however, soon pass away, leaving the patient much 
as before the attack. A time comes, however, when the digestive organs be- 
come disturbed, followed by loss of appetite, diminished strength, and pro- 
gressive emaciation. The patient presents a haggard expression, and often 
suffers from extreme depression of spirits and an utter indisposition to 
exertion. 
Sequels of stricture.-One of the most common results of stricture, as might 
naturally be supposed, from a column of water being forcibly impelled against 
an obstruction which allows only a few drops to escape at a time, is a dilata- 
tion of the urethra behind the seat of coarctation. This invariably occurs, 
in obedience to physical laws, at whatever point in the course of the canal 
the stricture exists. In accordance with the common seat of the disease, 
this dilatation is most frequently found at the membranous portion of the 
canal, and gradually implicates the prostatic. The sinus formed in this 
way becomes sufficiently large to hold several ounces of fluid. If there are 
multiple strictures, similar enlargements may exist behind each obstruction. 
The size of the canal is little altered in front of a stricture, though it appears 
to me that in old cases of the disease the capacity of the tube is somewhat 
lessened. This might be anticipated when we consider that the column of 
water which forms in front of a urethral obstruction of this nature is never 
of the normal size, and that consequently the tendency in this portion of the 
urethra would be to contract. Instances have been furnished of a dilatation 
in advance of a stricture; but the phenomenon appears to me to be incapable 
of explanation according to any law in hydro- 
dynamics. 
Rupture.-As an effect of dilatation, the walls 
of the urethra may become more and more 
attenuated, until, from inflammation, abscess, 
and ulceration, an opening occurs; or they may 
give way suddenly during the straining efforts 
exercised in micturition, causing, in either 
event, urinary infiltration and abscess, ending 
in urethral fistula. This accident usually takes 
place in the perineal part of the urethra, though 
the spongy portion may also suffer. Not only 
is the entire calibre of the urethra expanded, 
but the lacunae also participate in the dilata- 
tion, giving a reticulated or honey-combed ap- 
pearance to the mucous surface. 
Effects on the bladder.--The constant and 
forcible contraction of the bladder, put forth 
with a view to discharge its contents, induces 
enormous hypertrophy of its muscular coat, 
giving to the interior of the organ an appearance not unlike that presented 
by the columnae carneae of the heart (Fig. 1275), and as the water in the 
Fig. 1275. 
Interior of the bladder from a patient who 
suffered from stricture. 
VOL. II.-31 482 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
viscus is unable to escape, except in a very slow manner, it reacts against the 
muscular walls. This struggle between the two forces compels the organ to 
yield at certain points, giving rise to a sacculated or dilated condition of 
the viscus. 
In addition to the irritation arising from the difficulty of discharging the 
urine, the walls of the bladder are subjected to another, that incident to the 
decomposition of the retained water, with the precipitated products, ex- 
citing cystitis, and favoring the development of calculi. There may be, also, 
patches of ulceration on the mucous membrane, and abscesses in the walls of 
the bladder. 
Ureters and kidneys.-These parts of the urinary apparatus in old and ag- 
gravated cases become involved in the general structural devastation. The 
inflammation extends by continuity of tissue to the mucous membrane 
lining these cavities; the accumulation of water in the bladder dams the 
stream back in the ureters, and they become dilated or sacculated at one or 
several points in their course ; the kidney in turn suffers, the pelvis and 
infundibula becoming dilated until the entire organ is expanded into an im- 
mense cyst filled with urine, pus, and various inflammatory products. The 
history of such a case is not unfrequently terminated by the development of 
brain symptoms, occasioned by the introduction into the blood of poisonous 
urinary products. 
Treatment.-Although many and important advances have been made of 
late years in the treatment of urethral stricture, the more recent writers on 
this subject, like Acestes of old, seem to me to have aimed at a mark so far 
removed from the limits of human possibilities that the result has been 
failure. The radical cure of stricture 1 believe to be entirely beyond the reach 
of surgery, notwithstanding the immense and varied resources at her com- 
mand. This statement is not made in any spirit of depreciation of the labor 
of those who have given themselves with singular devotion to this branch 
of surgery. On the contrary, I both honor and admire the work which they 
have done; but this conclusion has been reached after no small experience 
both in private and in hospital practice, and after having patients who seemed 
to be cured, but who, years after, came back, with a return of their strictures. 
Experience, therefore, to say nothing of the anatomical peculiarities of the 
tissue which constitutes the coarctation of the urethra, compels me to speak 
strongly on this subject; and if it savors of dogmatism, it is that which 
originates in an honest conviction of the truthfulness of the statement, in 
maintaining which I find myself in the company of many good surgeons who 
entertain similar views. 
The indications in the treatment of urethral stricture are the restoration 
of the canal to its normal size, if this can be done without seriously com- 
promising the life of the patient, and the subsequent preservation of its proper 
calibre. It is necessary, therefore, to have a tolerably accurate notion of the 
exact size of the normal urethra. There is no doubt that anatomy has been 
a false light to surgery on this point. Works on anatomy tell us that the 
size of the urethra varies at different points, the smallest portion being the 
external meatus, and the largest and most dilatable part the prostatic. The 
external orifice is stated to be about one-fourth of an inch in diameter, and 
the largest division of the canal approximately about seven-tenths of an 
inch in circumference. It does not seem to have occurred to anatomists that 
there must necessarily be great variation in the capacity of the urethra, cor- 
responding to differences in the size of the penis. It appears to have been 
reserved for American surgeons to demonstrate several very important ana- 
tomical peculiarities belonging to this part of the penis and relating to the 
capacity of the urethra, and also to formulate certain rules fbr determining the 
size of each individual urethra or its average extensibility. Professor Otis, 
of New York, after making a large number of observations, has shown that 
there is a uniform relation existing between the circumference of the flaccid 
penis and that of the urethra. Thus, where the organ measured three inches STRICTURE OF THE URETHRA. 
483 
in circumference, the urethra in its calibre would be thirty of the French 
scale ; when it was three and a quarter inches, the capacity of the urethra 
would be thirty-two ; when it was three and a half inches, the capacity would 
be thirty-four, etc. In other words, for every quarter of an inch increase in 
the circumference of the penis over three inches, there will be a correspond- 
ing increase in the capacity of the urethra equal to two millimetres. The 
same surgeon has devised a urethra-metre, an instrument for measuring the 
calibre of the urethral canal. It consists of a straight canula, No. 8 size, 
ending in a number of short metallic bars connected with one another and 
with the canula by hinges, and which can be either closed or expanded into 
a bulb-shaped figure by a rod which runs through the canula the entire 
length of the instrument and is worked by a screw at the handle of the 
same. A dial-plate, with an index, marked off into millimetres, is also at- 
tached to the handle of the instrument. When the urethra-metre is used, a 
thin rubber sheath is drawn over the extremity of the closed instrument, in 
order to protect the lining membrane of the urethra. It is then well oiled 
and introduced into the canal, and the bars expanded to an extent not in- 
consistent with the free movement of the bulb when carried alternately up 
and down. The capacity of the urethra will be recorded on the dial-plate 
Fig. 1276. 
The urethra-metre of Otis. 
of the urethra-metre in millimetres. (Fig. 1276.) The advantages claimed 
for the instrument are the knowledge which it supplies of the calibre of the 
urethra, and of the locality and number of the strictures which may exist, 
without the necessity of withdrawing the urethra-metre and without reference 
to the size of the meatus. There can be no doubt that such information will 
prove of value in the treatment of stricture, as it fixes the extent to which 
the canal is to be dilated in order to be restored to its original calibre, and 
accordingly such measurements may be made preliminary to any plan of 
treatment the surgeon may choose to adopt. 
The means employed for fulfilling the indications stated are dilatation, 
divulsion, internal urethrotomy, and external urethrotomy. 
Dilatation.-This method is a very old, and, for a large number of strictures, 
a very satisfactory one. Dilatation may be gradual or rapid. 
Gradual dilatation is the safest of all measures for the treatment of stric- 
ture, and may be accomplished with soft or metal instruments. The soft bougie 
will be found to answer in a limited number of cases, when, for example, the 
urethra at the strictured part of the canal is sinuous, or when the calibre of 
the latter is very small. These bougies are of two kinds, the conical and the 
olive-shaped. (Figs. 1277, 1278.) 
Fig. 1277. 
Conical soft bougie. 
Fig. 1278. 
The extreme flexibility of the extremities of these instruments renders them 
capable of being passed through a tortuous passage which might with a 
metallic bougie be impervious. 
My personal preference, however, after having rendered the route through 
Olive-shaped bougie. 484 
INJURIES AND DISEASES OF THE GENITOURINARY ORGANS. 
the urethra safe by the soft bougie, is for the steel instruments. They should 
be perfectly smooth, with a stout broad handle, a well-rounded conical point, 
with a curve similar to that advised for the catheter, and should be nickel- 
plated, in order to prevent the surface from becoming tarnished by exposure 
to the air. 
They are of graduated sizes, answering to certain scales which have been 
adopted as the basis for measurement, but which, unfortunately, are not 
uniform. The English scale contains fifteen numbers (Fig. 1279), the 
Fig. 1279. 
English catheter scale. 
increase in size being very considerable between any two numbers. The 
American scale, constructed on the metric system, is an improvement over 
the English, the numbers ranging from one to twenty-one, and increasing each 
by half a millimetre in diameter. The French scale (Fig. 1280) has also the 
Fig. 1280. 
French catheter scale. 
advantage of being much better graduated than the English. It contains 
thirty numbers, one-third millimetre in diameter being the basis of measure- 
ment, and consequently the rise from one size to another is very gradual. 
In order to obtain absolute accuracy in the measurement of dilating instru- 
ments for the urethra, Dr. Charles Thomas, of Philadelphia, has devised a 
very simple and at the same time perfectly correct gauge for the purpose, 
inasmuch as the size is not indicated by arbitrary numbers, but by circum- 
ferential or perimetric measurements, expressed in millimetres, as in the 
French scale. (Figs. 1281, 1282.) It is made from heavy bank-note or bond 
paper, and is quite durable. 
This gauge has a special advantage over all others, in that it is equally 
adapted for the measurement of instruments of irregular as well as regular 
form. 
If the stricture is very irritable, the patient should be subjected to some 
preliminary treatment before any instrument is employed. Twenty-four 
hours' rest in the recumbent position, one or two warm hip-baths, the absence 
of all stimulants, the free use of alkaline diluent drinks, and an injection of 
laudanum, or a suppository of opium, will generally be sufficient to tranquillize 
the general system and allay the local irritation, when the use of the instru- 
ment may be begun. 
The recumbent position is the one best adapted for the manipulation. Select- 
ing an instrument larger than is likely to pass the obstruction, carry it, after 
being warmed .to .the temperature of the body and well oiled, gently along STRICTURE OF THE URETHRA. 
485 
the canal, until the point becomes arrested by the stricture. 
Should it not pass, let it be withdrawn with the same care as 
Fig.1281 
Fig. 1282. 
Thomas's gauge looped, showing mode of application. 
was observed in its introduction, and a second and smaller-sized 
tried. If there is reason to believe that the bougie is not dispropor- 
tionately large for the coarctated canal, let the operator, should 
he meet with some opposition, not remove the instrument prema- 
turely. Let it be withdrawn and again advanced, and this re- 
peated a number of times. Let the point be directed first in 
one direction and then in another, and probably, after a few 
attempts, the difficulty will be overcome and the stricture passed. 
During the whole procedure very little force is necessary, the 
great requisites to success being patience, gentleness, and a light 
hand. Once through the obstruction, the instrument should be 
removed, the patient remanded to bed, and, if the stricture is an 
irritable one, a suppository of opium may bo introduced into the 
bowel and eight or ten grains of quinine immediately administered 
by the mouth, in order to prevent the occurrence of urethral chill. 
Two or three days later will be quite soon enough for a second 
use of instruments, and then it is always advisable to pass the 
size last introduced, and advance one or two numbers of the scale 
at each sitting, and, if -well borne, the operator may proceed more 
boldly, and allow the bougie to remain in the urethra for a period 
of four or five minutes. If little or no irritation has followed 
the use of the instrument, it will not be necessary to adopt the 
precautionary measures against urethral chill which were de- 
manded in the first instance. In this manner the dilatation is 
carried on until the normal capacity of the canal is attained. 
This is probably effected not by stretching alone, but by inducing 
an absorption of the surrounding inflammatory deposits. 
After the stricture has been dilated so as to admit a large in- 
strument, the surgeon has another duty to perform, and that is, to 
instruct the patient in the use of the bougie. Under most circum- 
stances any person of ordinary intelligence and tact can readily 
acquire the ability to introduce a bougie into his own urethra; 
and, as the tendency to subsequent contraction in all cases of 
stricture is invariable, it is important that the patient should be 
forearmed before passing from under the supervision of his medi- 
cal attendant. For this purpose it is not necessary that he should 
use the largest instrument of the scale. On the contrary, a No. 
24 or 25* is quite ample for all practical purposes, and should 
be inserted once or twice a week at first for a few weeks, and 
afterwards once every two weeks. 
A very distinguished authority has advised that in passing an 
instrument the operator should " forget all about his anatomy." 
I must beg leave to differ from this injunction, and to say that to 
forget one's anatomy at such a time is to act like a shipmaster 
who throws away his compass in mid-ocean. The author of that 
sentiment, although from long and large experience he may not 
know it, owes, I doubt not, his exceptional skill in this depart- 
ment of surgery to the unconscious exercise of what he decries. 
Thomas's 
adaptable me- 
tric gauge. 
* Whenever allusion is made in the text to the sizes of urethral instruments, the 
French scale is employed. 486 
INJURIES AND DISEASES OF THE GENITO-URINARE ORGANS. 
In all cases, then, where dilatation can be effected, that operation, being 
almost entirely devoid of danger, should be preferred ; but there are diffi- 
culties which will be frequently encountered in passing a stricture 
and entering the bladder, from the extreme narrowness or tor- 
tuousness or thickening of the diseased part of the channel, and 
which demand attention. These are embarrassing complications 
to the young practitioner, but while they are exceedingly trouble- 
some they are not insurmountable. As long as the urine can 
find its way out through the urethral canal, even though it is 
only in drops, the route to the bladder in the opposite direction 
is not impassable by instruments in a skillful and patient hand. 
This maxim was long ago announced by Syme, and experience has 
proved its correctness. It would obviously be unsafe to per- 
severe wholly with the metallic bougies under such circum- 
stances. Filiform instruments of whalebone 
or of gum (Fig. 1283) will be found of the 
greatest value. 
Whalebone bougies are prepared with 
straight, angular, or spiral extremities, the 
points being olive-shaped. They are capital 
searchers, and can be introduced through a 
very tortuous passage. The direction of the 
canal once ascertained, larger instruments can 
be employed, until the route is made suffi- 
ciently capacious and direct to admit of the 
use of the ordinary hard or soft bougies. But 
it is even possible to pass a filiform bougie 
and yet not be able to follow it with another 
instrument. In such cases we have a valuable 
resource in the instrument of Professor Otis, 
which consists of a long, soft, filiform bougie 
and a hollow metallic instrument similar to 
a catheter. (Fig. 1284.) 
This is one of the safest means of over- 
coming a narrow or sinuous stricture. A 
filiform gum bougie eighteen inches in length 
is first passed along the urethra to the seat 
of obstruction, when the flexible point usu- 
ally enters the orifice and glides through the 
narrow passage into the bladder. The part 
of the filiform instrument which remains out 
of the urethra is then passed through the 
hollow bougie, which, after being introduced 
into the urethra, is pushed forward over its 
guide until piloted into the bladder. A repe- 
tition of this process will soon remove the 
embarrassment. This principle of slipping 
tubes of graduated sizes over a guide pre- 
viously introduced into the bladder was long 
ago adopted by Mr. Thomas Wakely, of Lon- 
don (Fig. 1285), and with various modifica- 
tions has been employed from time to time by 
Desault, Buchanan of Glasgow, Maisonneuvc, and others. 
Sometimes we succeed, when the stricture is seated in the membranous 
part of the urethra, in getting the point of a bougie engaged, but feel a de- 
gree of uncertainty about applying the force necessary to pass the coarcta- 
tion, for fear the instrument may be deflected from the proper course. In 
such a strait, a finger introduced into the rectum, and used as a guide, will 
enable the operator to effect bis object with comparative safety. False pas- 
Fig. 1283. 
Fig. 1284. 
Filiform 
whalebone 
bougies. 
Hollow bougie passed over 
the filiform guide. STRICTURE OF THE URETHRA. 
487 
sages not unfrequently are a source of deception, by leading the instrument 
astray. A careful exploration of the urethra will generally enable the sur- 
geon to determine on which 
aspect of the canal the ab- 
normal opening exists, when 
it may be avoided by giving 
the point of the bougie an 
opposite direction until the 
region of danger is passed. 
Another stratagem adopted 
to overcome the same com- 
plication, and practiced by 
Mercier, is to introduce into 
the false passage the end of 
a solid metallic catheter, and 
then project through its eye, 
which is placed a short dis- 
tance back, a second flexible 
instrument; then, after di- 
recting the latter into the 
true passage, the former can 
be withdrawn. 
There are strictures in 
which the urethra is trav- 
ersed by a reticulation of 
bands, and in which the la- 
cunae become dilated, so that 
the point of a small instru- 
ment is likely to pass into 
one of these rather than into 
the propei* channel. In such 
cases these closed cavities 
or recesses can be filled by 
inserting a number of filiform whalebones, which will lessen the chances of 
the bougie missing the normal course. 
Continuous dilatation may become necessary in cases where the circum- 
stances are such that it is necessary to effect the dilatation in a short time, 
or where it is found, after each dilatation by the gradual method, that the 
stricture tends to return to its original size; and here the soft catheter is 
always to be preferred, provided it can be introduced. Until this can easily 
be done it is better to postpone a resort to this method. 
It is necessary that the patient should be confined to bed during the treat- 
ment. The instrument, which should be one that will not fill the stricture 
tightly (otherwise it will defeat the object by causing irritation, congestion, 
and greater infiltration), must be passed barely into the bladder, and then 
secured in position by one of the methods directed for retaining the catheter. 
The object is not to stretch the coarctation, but to cause the latter to embrace 
the catheter: this pressure will be graduated spontaneously by the toler- 
ance of the parts concerned. The instruments should be exchanged for larger 
ones every two or three days for a period rarely longer than a fortnight, al- 
ways observing the rule already laid down, that the catheter shall pass the 
stricture without any resistance. During the treatment by this plan the instru- 
ment must be closed with a cork, which can be removed at stated intervals 
to allow the escape of urine. 
After the urethra has in this way been considerably enlarged, the remain- 
ing part of the treatment may be carried on by periodical dilatation with 
steel instruments. 
Divulsion.-A word derived from the Latin divello, " I tear or pull asunder," 
Fig. 1285. 
The Wakely instruments for dilating strictures by the passage of 
graduated tubes. 488 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
has been employed to designate an operation which consists in rupturing or 
lacerating the tissues involved in a stricture and restoring the urethra to 
its proper size. The operation cannot be considered a recent one, but was 
practiced as early as 1835 by Perreve, a French surgeon, and at a later period 
by Professor Gross and other American surgeons. The original dilator or 
divulsor (for it was used for both purposes) designed by Perreve consisted 
of two thin blades united only at one-the vesical-extremity, and several 
rods of different sizes which were used for wedging the blades apart after 
the latter were passed through the stricture. An important improvement 
was afterwards made by this surgeon on his first instrument, by having 
a filiform gum bougie connected to its extremity as a guide in very close 
strictures. In England, where the operation is called splitting or rupture, 
divulsion was introduced chiefly through the influence of Mr. Holt, of the 
Westminster Hospital, who designed a modification of the Perreve instrument. 
(Fig. 1286.) Richardson's divulsor, a modification of Holt's, consists of 
Fig. 1286. 
plungers and of two slightly concave blades inseparably joined and olive- 
shaped at the vesical extremity, the other ends being fitted into a handle 
supplied with a screw designed to regulate the separation of the blades. 
Various other modifications of the original mechanism have been made 
from time to time, though in no way affecting the principle of operation. 
Among these may be mentioned the instruments of Voillemier and Thomp- 
son. It is a matter of little importance what instrument is used, so that 
the coarctated tissues are torn; though that of Thompson has certain ad- 
vantages over others. The value of this instrument has been materially 
increased by the alterations which it has undergone in America, namely, 
by rounding the first two inches of the blades to prevent the mucous mem- 
brane from being punctured, and by having its extremity tunneled for the 
passage of a guide in cases of close strictures. The best of these modifica- 
tions is that of Billings (Fig. 1287), in whose instrument the last three-quar- 
ters of an inch is a hollow tube, which materially lessens the chances of 
Holt's divulsor. 
Fig. 1287. 
Billings's divulsor. 
pinching or lacerating the mucous membrane, as in the case of divulsors in 
which the blades at this point are separable. STRICTURE OF THE URETHRA. 
489 
The manner of effecting the laceration by Holt's instrument is to introduce 
the divulsor through the stricture with the blades closed, when the latter 
are released by reversing the turns of the screw. The plunger is then intro- 
duced between the blades and driven home with a forcible impulse of the 
band. Sometimes the plunger is passed down over a hollow guiding-rod added 
to the divulsor for the introduction either of a stylet or of a filiform guide. 
In the use of Thompson's dilator, which can also be made a divulsor, the 
instrument is passed through the stricture, when the blades are rapidly sepa- 
rated chiefly at the seat of constriction by turning the handle until the object 
is believed to have been obtained. The mechanical power employed is not the 
same in the two instruments described. In that of Holt and in all others 
constituted on the same principle the divulsion is effected by the wedge; in 
that of Thompson, by direct expansion. In both, however, the mucous mem- 
brane can be torn in a longitudinal direction, and the tissues beneath more 
irregularly. The gap which is thus produced in the canal must be closed by 
granulation and cicatrization. 
After the removal of the instrument there will be a discharge of blood 
from the urethra, provided the laceration has occurred,-a fact which will be 
further assured by the readiness with which a large-sized bougie, No. 18 or 
20, can be passed. If the operation has failed in this respect, it will be either 
in consequence of the blades .of the divulsor not having been sufficiently sepa- 
rated, or from some quality inherent in the stricture, as that of unusual elas- 
ticity. After the laceration has been completed and the instrument removed, 
a large-sized catheter should be passed into the bladder and the urine with- 
drawn. No instrument is to be retained in the urethra, though the same 
catheter is to be inserted every other day for a period of two weeks or more. 
Quinine and opium are also to be administered during the first twenty-four 
hours, with a view to prevent urethral fever. 
The operation of divulsion is thought by some surgeons to be peculiarly 
well adapted to the treatment of irritable, resilient, or elastic stricture. 
It is a rough, violent surgical procedure, and by no means free from danger. 
Encouraged by the representations of its advocates, I was induced to adopt 
the method in what I supposed were wTelI-selected cases, but soon had cause 
to regret the practice, by having a fatal case occur in my bands. There are 
two facts which, in my judgment, militate against divulsion. First, nothing 
is accomplished which cannot be obtained by gradual dilatation. It is true 
the latter is a slow process; but I can conceive of no reason connected with 
a mere consideration of time which justifies a surgeon in jeopardizing the life 
of his patient. Secondly, the tendency to the reformation of the stricture is 
not lessened by divulsion. After laceration of the tissues an ulcer is left, and 
this can be repaired only by granulation and cicatrization. The new tissue 
will never become like the normal urethra, but will tend to contract, and 
■will certainly demand the repeated use of bougies for an indefinite period. 
The most cautious advocates of the divulsive plan are disposed to limit its 
application to strictures located in the penile part of the urethra. 
Rapid dilatation is a plan which professes to accomplish in a few moments 
that which by gradual dilatation would require many days. It occupies, 
therefore, a middle ground between the latter process and that of divulsion. 
It is no doubt true that in rapid dilatation the mucous membrane and the 
submucous tissues are often unwittingly torn; but this is not the object of 
the operator. 
The plan is an old one. As early as 1812, Mr. Luxmoor, an English sur- 
geon, employed for this purpose an instrument having four blades, which 
may be considered as having suggested a number of other similar appliances, 
-some with two and others with three blades,-devised by Mr. Weiss, a sur- 
gical cutler of London. The same end was effected at a later period by a 
succession of graduated tubes, one capable of being slid down over another. 
Chronologically considered, the most important of this class were the instru- 
ments of Desault, Buchanan, Hutton, Maisonneuve, and Wakely, the first 490 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
dating back as early as 1797 or 1798, and the last to 1850. Those of Wakely 
are the most perfect of the kind. A small catheter is first introduced into 
the bladder, and a metal guide secured to its end. Over this are passed in 
succession tubes of different sizes, which rapidly dilate the stricture. The 
most complete rod dilators are those of Thompson (Fig. 1288), and of Rigaud 
(Fig. 1289) and Michelenas, Mathews and Thompson. 
The last is to be preferred, as the dilating part of the 
instrument is limited to a small portion of the blades. 
I do not believe that any advantage is gained by this 
mode of treatment. If the capacity of the canal is to be • 
approximately restored by the removal, through a retro- 
grade metamorphosis, of the new formation constituting 
a stricture (and doubtless this enters largely into the pro- 
cess), reasoning from analogy, it is much more likely to 
be effected by gradual than by instantaneous force. 
Besides the plans enumerated, dilatation has also been 
attempted by rods of laminaria and by hydrostatic pressure 
as employed by Du Camp, by Arnott, and 
by Steurer. 
Internal Urethrotomy, or Incision.-Ure- 
throtomy is doubtless a very ancient oper- 
ation, practiced in the beginning of the 
Christian era. The contrivances, howTever, 
which were employed in early times were 
exceedingly rude and imperfect, consisting 
of tubes through which were passed rods 
and stylets variously fashioned in order to 
scarify, puncture, or drill the obstructions. 
The earliest practical advance in the instru- 
mental part of this mode of treatment is 
due to Physick, who, in 1795, designed a 
catheter bearing a concealed lancet which 
could be projected at pleasure. For the con- 
struction of the sheaths and knives which 
are now in general use we are indebted to 
Civiale in France, to Jamieson in America, 
in 1827, and to Stafford in England. The 
instruments of the last two surgeons were 
published at the same time, but were doubt- 
less originated entirely independent of each 
other. 
A great variety of urethrotomes have been 
constructed, among which may be named 
those of Civiale, A. Reybert, Maisonneuve, 
Gibson, Sedillot, Wood, Trelet, Thompson, 
Teevan, Pancoast, Otis, Mastin, and Gross. 
Some of these urethrotomes divide the stric- 
ture from before backward, and others from 
behind forward: the latter are the safer instruments and should be preferred. 
Those of Mastin, of Otis, and of Gross (Fig. 1290) embody everything 
necessary to the successful execution of the operation. The instrument of 
Gross, like that of Civiale, has a bulbous extremity, which enables the oper- 
ator to locate with accuracy the precise limits of the coarctation. 
Preliminary to the operation of urethrotomy it is necessary to dilate the 
stricture by a bougie to an extent sufficient for the admission of the instru- 
ment. 
Operation.-The patient being under the influence of ether, a bougie (No. 
7 or 8, French scale) is passed through the constriction; on its withdrawal the 
Fig. 1288. 
Fig. 1289. 
Thompson's dilator. 
Rigaud's dilator. INTERNAL URETHROTOMY, OR INCISION. 
491 
urethrotome is introduced and pressed through the stricture, the passage of 
which can readily be determined by the freedom with which the bulb is felt 
to move in the canal beyond. Satisfied on this point, the operator now com- 
mences his incision a short distance on the vesical side of the coarctation, by 
pressing out the blade, directing it against 
the lower wall of the urethra, and then 
steadily withdrawing the instrument, the 
resistance to which will be felt increasing 
as the dense tissue of the stricture is 
encountered, and again lessening as the 
knife leaves its anterior face. The blade, 
however, should not bo allowed to recede 
into the bulb until after the obstruction 
has been passed a short distance. The 
incision, if made properly, should extend 
at least from a quarter to half an inch on 
both sides of the stricture, and is much 
more likely to be too little than too free. 
A few drops of blood follow the with- 
drawal of the urethrotome, when a large- 
sized metallic catheter must be imme- 
diately passed. Should this be embraced 
to a degree which prevents the instru- 
ment from being easily slid up and down 
in the canal, there is some part of the 
stricture remaining undivided, and the 
urethrotome should be reintroduced, the 
incision repeated, and the catheter again 
inserted, to ascertain the completeness of 
the division. If this proves satisfactory, 
the metallic catheter should be replaced 
by a soft one, to be retained, a two-grain 
suppository of opium should be intro- 
duced into the rectum, and the patient 
remanded to bed. By retaining the cath- 
eter the wound is protected against the 
irritating effects of the urine, and, con- 
sequently, there is less liability to consti- 
tutional disturbance. The instrument, 
however, should not be allowed to remain 
longer than two days, when it must be 
removed. After this it will be necessary 
to pass every three or four days a metal 
bougie (No. 25 or 26, French scale), 
taking care to keep the point in gentle 
contact with the anterior wall of the 
urethra as the instrument is carried 
down, so as to avoid the wound in the 
canal. After two weeks the use of the 
bougie will not be required oftener than 
once a week, and finally once in two or 
three weeks. Professor Otis has combined in a most ingenious manner in 
the same instrument a urethrotome and a dilator. (Fig. 1291.) With this 
mechanism the stricture is divided along the upper wall of the canal and 
from before backward, and then without withdrawing the instrument the 
blades of the dilator are separated to an extent corresponding to the normal 
calibre of the urethra. The amount of separation is indicated by the dial- 
plate of the instrument. 
The instrument of Dr. Mastin also embodies the dilator, urethrotome, and 
Fig. 1290. 
Fig. 1291. 
Gross's urethro- 
tome. 
Otis's dilating urethrotome, 492 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
dial-plate in one. The form of its extremity, that in which the knife is con- 
cealed, is particularly well adapted to communicate to the hand a precise 
knowledge of the extent of the coarctation, and, consequently, to render the 
incision exact. (Fig. 1292.) 
Fig. 1292. 
Mastin's dilating urethrotome. 
In all cases of resilient or irritable stricture, when little progress is made 
by dilatation, internal urethrotomy, especially in any part of the penile 
urethra, is a most valuable resource, infinitely superior to and safer than 
either forced dilatation or divulsion. In selecting a urethrotome, I do not 
think it a matter of much practical importance which of those described is 
employed. 
The incision is a clean cut, and not a violent, rough laceration and mutila- 
tion of the diseased tissues, such as is inflicted by the divulsors. It is, con- 
sequently, followed by much less inflammation and infiltration than the 
operation done by the latter instruments. 
Dr. Mastin has performed internal urethrotomy three hundred and twenty 
times without a single death. No better commentary on the safety of the 
operation than this can be asked. But, however valuable may be incision, it 
must not be deemed a radical cure for stricture, notwithstanding what is said 
to the contrary by sanguine urethrotomists. The splice, of which so much is 
said, and which occupies the gap between the sides of the divided parts, is 
granulation tissue; and the resulting cicatrix will always retain that in- 
vincible property of contraction. The tendency to coarctation in the canal 
is, it is true, lessened, but it is not destroyed ; and hence the patient must be 
instructed to pass a metal sound once or twice every month if he expects to 
keep out of the hands of the surgeon at some future time. 
Caustics.-The treatment of stricture by caustics was practiced at different 
times for several hundred years, and indeed was employed within the present 
century. The agents used were sulphate of copper, caustic potassa, nitrate 
of silver, and other corrosive agents. These remedies, as applied to stric- 
ture, have deservedly fallen into disuse. 
In summing up, then, the local treatment of urethral stricture, I believe 
that it is embraced under two heads: first, and always first, dilatation; and, 
secondly, failing in this, incision or internal urethrotomy, followed by dilatation. 
External Urethrotomy.-It is barely possible that the tissues around a 
stricture of the urethra may be so altered as to render the passage of an in- 
strument impossible and require an extended incision in order to open an 
unobstructed route to the bladder. These operations at one time were very 
common, and were sometimes performed in cases where the urethra was 
permeable. On the permeability or non-pcrmeability of the stricture are 
based the operations distinguished as external urethrotomy performed with 
a guide and external urethrotomy performed without a guide, the latter 
procedure being known as perineal section, or one form of the boutonniere. 
External urethrotomy on a guide.-This operation was advocated by Mr. 
Syme in 1844. In its performance the patient, being etherized, is placed in 
the lithotomy position, and the hair shaved from the perineum. A Syme 
staff (Fig. 1293) is next passed through the stricture as far as to the shoulder EXTERNAL URETHROTOMY. 
493 
of the instrument, which is then committed to an assistant, who is directed 
to hold it steadily against the obstruction. The operator, sitting in front of 
the patient, makes an incision in the middle of the perineum dividing the 
tissues, with the back of the knife always towards the 
anus, until the staff can be felt with the finger, at the 
same time taking care not to open the deep perineal 
fascia. Entering the knife at the commencement of the 
groove in the large part of the instrument, and carry- 
ing it from before backward, he divides the stricture, 
together with a portion of the normal urethra, some 
distance in front and behind. If the operator has been 
careful not to deviate from the median line, very little 
blood will be lost. To avoid the possibility of per- 
forating the urethra or entering into some false pas- 
sage (a mistake which might easily be committed with 
an instrument having so delicate and rigid an extremity 
as that of Syme), Gouley uses a catheter staff which 
is grooved, except at its end, which is tunneled, and 
through which can be passed a filiform whalebone guide. 
(Fig. 1294.) 
Fig. 1293. 
Fig. 1294. 
Gouley's catheter staff. 
After the free division of the stricture, the staff can 
be carried forward through the divided parts, or it can 
be withdrawn and a catheter passed along the urethra 
into the bladder, where it may be allowed to remain for 
twenty-four hours. The passage of the catheter will be 
facilitated by adopting the plan of Thompson,-that of 
first introducing into the urethra, through the wound, 
in the direction of the bladder, a director with a capa- 
cious groove. 
After the removal of the catheter it will only be neces- 
sary to introduce daily a large-sized metallic sound until 
the external wound has almost healed, when by drawing 
the urine at proper intervals with a catheter the perineal 
opening will soon close. The operation is attended with 
a very low death-rate, only 7 deaths having occurred 
in 219 cases collected by Thompson. 
External perineal urethrotomy without a guide is an operation demanding the 
most consummate patience and tact. It was performed as early as 1662 by 
Molins, an English surgeon. The patient is placed in the lithotomy position, 
and a grooved staff carried along the urethra until it encounters the stric- 
ture, against which it is to be held, while the surgeon, keeping in the middle 
line, divides the superincumbent tissues and opens the urethra on the staff 
in front of the obstruction. The edges of the wound are now to be drawn 
asunder by threads inserted through each, and, with a good light directed 
into the opening, the dense tissues of the stricture are to be carefully ex- 
plored with a probe or a filiform guide of whalebone in search of the urethra. 
If discovered, a grooved director can be passed and the stricture divided. If, 
after a diligent examination, no opening can be detected, it will be necessary 
Syme's staff. 494 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
to lay open by installments the indurated tissue which composes the stric- 
ture, at each step renewing the attempt to detect the canal. Failing in this, 
and having incised the thickened structures, the search should be continued 
on to the vesical side of the stricture until the urethra is discovered, when 
the staff can be carried forward into the bladder or can be withdrawn and 
replaced with a catheter. 
This operation has passed under the names of perineal section, boutonniere, 
perineal urethrotomy, and more recently external urethrotomy. It is a very 
ancient procedure, having been executed for a variety of purposes, particu- 
larly for the extraction of foreign bodies from the urethra. It was advised 
in the latter part of the first century by Aretams for the removal of calculi 
which became impacted in the urethra. As an operation for the relief of 
retention it was noticed both by Rhazes and by Avicenna, the former be- 
longing to the tenth and the latter to the eleventh century. Its reduction 
to a system, however, does not appear until 1525, when, as a preliminary 
measure to a method of lithotomy known as the major apparatus, perineal 
urethrotomy was popularized by a surgeon of Cremona, Giovanni, and his 
follower, Mardanosanto. The first instance which can be regarded as au- 
thentic of perineal urethrotomy performed for stricture is that recorded by 
Richard Wiseman, in 1652. This operation was followed by those of Solingen, 
and about 1690 by those of Tolet and Colot. La Faye mentions the opera- 
tion and the manner of executing it in 1765; and in 1730 Le Dran gives an 
account of having treated an impassable stricture by this method. In 1783 
the perineal section was done by John Hunter at St. George's Hospital, 
London, after which we hear little about the operation until 1815, when it was 
again agitated by Mr. Granger, of Birmingham, followed by Mr. Arnot and 
Mr. Guthrie. Professor Gouley, to whom we are indebted for an excellent 
resume of the literature of this subject, has given a chronological notice of 
the operations in America, which were first advocated and performed by 
Alexander II. Stevens, of New York, in 1817; in 1820 and 1823 by Dr. 
Jamieson, of Baltimore, who operated ten times successfully; by Dr. David 
L. Rogers, in 1823, and who reported twelve cases ; by Dr. J. C. Warren, of 
Boston, and others by Drs. Hoffman, Post, Watson, and Buck. 
The popularity of the operation will appear from the fact that the books 
of the New York Hospital record seventy-five cases. To Mr. Syme and to 
Drs. Van Buren and Gouley we are indebted for the improvement in the 
instruments employed in the operation. 
The success of this operation will depend on the sound condition of the 
internal organs, especially the kidneys, on the character of the perineum, 
which is less favorable in obese subjects, where the urethra lies very deep, 
and on the skill with which the task is executed. Success depends much, 
very much, on confining the incisions to the middle line and avoiding all 
lateral dissections. In 345 cases of external urethrotomy performed by 
American surgeons and collected by Gouley, 233 of which were performed 
without a guide, there were 40 deaths, a mortality of 12 per cent. A different 
result is exhibited in the 35 cases collected from the practice of German and 
French surgeons by Boeckel, 8 of whom died, or a mortality of 28.85 per 
cent. 
Subcutaneous urethrotomy.-This operation, suggested by Dick, consists in 
introducing obliquely through the tissues a narrow-bladed bistoury resem- 
bling a tenotome, and dividing the stricture on a grooved staff previously 
passed into the urethra. Dr. Mastin, of Alabama, and Mr. Teevan, of London, 
have each performed an operation of a similar nature. 
Diseases of the Prostate Body. 
The prostate is a musculo-glandular body, the muscular element predomi- 
nating very much over the glandular. It is very small in children. Its size 
is notably increased about the period of puberty, in accordance with the DISEASES OF THE PROSTATE BODY. 
495 
changes which occur at that time in the sexual organs, with which it is in- 
timately associated in functions. The contraction of its muscular compo- 
nent projects the semen from the prostatic sinus during the culmination 
of the venereal orgasm. It therefore sustains a peculiar sympathetic relation 
with the nerves of this part of the urethra. The position of the prostate 
with regard to the bladder, the urethra, the ejaculatory ducts, and the 
rectum, and its intimate relations to all four, impart additional importance 
to its diseases. 
Inflammation of the Prostate.-Inflammation of the prostate body is 
rarely met with as a primary affection, being in most instances secondary to 
urethritis, cystitis, and stricture, or being due to traumatic causes, such as 
the injudicious use of sounds, bougies, strong cauterizations, impaction of a 
stone, and lacerations in the extraction of urinary calculi. The inflammation 
may be acute or chronic. 
Acute inflammation.-The earliest sign of acute prostatitis is a feeling of 
weight and fullness in the perineum and rectum, with more or less uneasiness 
about the neck of the bladder, accompanied by a frequent desire to pass 
water, pain being experienced at the termination of the act. These symp- 
toms, which at first are not very marked, become more and more urgent as 
the inflammation increases; the desire to urinate is constant and irresistible; 
the pain, at first dull and intermittent, grows in severity, is throbbing, dart- 
ing, and continuous, and is no longer confined to the perineum, but radiates to 
the back, down the thighs, to the anus, testicles, and along the spermatic 
cords and the urethra. Indeed, it travels in all those directions in which there 
are nervous cords communicating with the hypogastric plexus. The suffer- 
ing is greatly aggravated by micturition and defecation. Even walking or 
sitting augments the distress. The difficulty experienced in passing water 
increases with the inflammatory swelling of the gland until it may amount 
to complete retention. 
The local symptoms are usually attended with general disturbance of the 
system, marked by rigors, increased heat of surface, an elevated temperature, 
a full and frequent pulse, thirst, loss of appetite, and a loaded tongue. When 
the rigors are repeated and the throbbing of the perineum continues, sup- 
puration may be anticipated, and if the urine is carefully examined it will 
usually be found to contain pus. 
Diagnosis.-Acute prostatitis may be confounded with cystitis and urinary 
calculus; but the distinction may be established by attending to the following 
considerations: 
PROSTATITIS. 
Not a common disease. 
Pain chiefly restricted to perineum and anus 
and accompanied by fullness. 
Pain is violent and throbbing. 
Stream of urine diminished in size. 
Pain aggravated during defecation. 
Retention of urine probable. 
Digital examination of the rectum reveals 
marked swelling and tenderness of the prostate. 
CYSTITIS. 
A common disease. 
Not so limited, and little, if any, perineal or 
rectal fullness. 
Is not. 
Stream of urine may be normal in size. 
Not necessarily so. 
Improbable. 
No enlargement, and little tenderness. 
Stone in the bladder is readily distinguished from prostatitis by the pain 
being always referred to the meatus and felt at the end of urination; by 
the absence of constitutional disturbance; by the gradual development of the 
vesical symptoms; and especially by the rough sensations communicated to 
the hand through the medium of the sound. 
The pathological changes which characterize acute prostatitis are vascular 
engorgement, transudation, and infiltration of the connective tissue of the 
body with inflammatory products, as lymph, blood, and pus. The latter, 
when present, are not usually confined to an isolated portion of the gland, 
but disseminated generally through its substance, which is sometimes appre- 
ciably soft and friable. 496 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Acute prostatitis runs its course in seven or eight days, terminating in 
resolution, chronic inflammation, or suppuration. 
Treatment.-Acute prostatitis is a disease which demands prompt and 
active treatment. In a strong, vigorous patient general blood-letting may be 
employed ; but usually the same object is attained, and even more quickly, 
by the free application of leeches to the perineum. Afterwards an active 
saline purge should be administered, followed by cnemata, and by large hot 
poultices over the perineum, frequently repeated. As a substitute for the 
latter, hot hip-baths may be employed, or the vapor of hot water may be 
used, by slipping a piece of rubber hose over the spout of a tea-kettle and 
carrying its free end beneath the clothing to the perineum, against which the 
steam is allowed to escape. 
Should the swelling of the prostate cause obstinate retention of the urine, the 
catheter, though it gives rise to pain, must be used three times in the twenty- 
four hours to relieve the bladder, as the continued presence of the urine will 
serve to aggravate the local distress. The urine must be kept bland and diluted 
by the free use of flaxseed or slippery-elm tea ; and when the patient is in bed 
the hips should be elevated, in order to take off the tension of the blood-ves- 
sels of the pelvis. For some time after the acute symptoms have vanished 
there will remain considerable swelling of the gland from the presence of 
the infiltration, which, by encroaching on the urethra, will materially lessen 
the size of the stream of urine and cause some difficulty in its free expulsion. 
This, like all inflammatory depositions, requires time for its removal, which 
can only be effected by the venous and lymphatic vessels. At this stage of the 
disease, and when all the urgent symptoms have disappeared, both patient 
and physician are sometimes betrayed into a false security, supposing that 
the cure is accomplished and little further attention required. No greater 
mistake can be committed. If the patient is allowed to rise from his bed and 
to go about, if he ventures to indulge in wine, or to give the reins to his 
sexual inclinations, a passive congestion of the gland will, in all probability, 
ensue, on which is laid the foundation of a permanent hypertrophy. Hence 
at this stage of the disease we should insist on continued rest in the recum- 
bent position, on keeping the bowels in a soluble condition, and on giving 
from time to time an alkaline diluent, to render the urine as bland as possible, 
and the iodide of potassium for the benefit of its resolving power over plastic 
deposits. 
Chronic Prostatitis is a sequel of the acute disease, rarely appearing as a 
primary affection. There is some enlargement of the prostate, a slight ten- 
derness when the gland is pressed upon with the finger, a discharge of glairy 
mucus, a feeling of weight in the perineum or at the end of the bowel, and 
an ache or pain experienced during the sexual orgasm and in passing the 
urine, which cannot be projected with any force from the urethra, and, in 
addition to being cloudy, deposits on standing a muco-purulent sediment. 
Treatment.-A patient who labors under chronic inflammation of the 
prostate following an acute attack ought not to be allowed for some time to 
remain on his feet. He should assume a recumbent position, though not 
necessarily in bed. A few leeches at intervals of every four or five days 
should be applied to the perineum, and these may be followed by a small 
blister or by two or three threads introduced as a seton. Quinine, iron, and 
strychnine will be required to restore the general strength, which has neces- 
sarily suffered from the preceding acute attack. Ergot will be found very 
useful in these cases, by inducing a tonic contraction of the muscular con- 
stituent of the prostate, thus favoring the absorption of the plastic infiltra- 
tion which permeates its structures; its efficacy will be increased by ad- 
ministering the remedy with the iodide of potassium (ext. ergot, fid., gr. xv; 
potass, iodid., gr. vi; aqurn, 5ii) three times a day. 
When the patient is harassed with nocturnal emissions, the sensibility of 
the prostatic sinus should be diminished by applying to this part of the PROSTATIC ABSCESS. 
497 
urethra, with the proper instrument (Fig. 1295), a solution of nitrate of 
silver (nitrate of silver, grs. xv; distilled water, §i). 
Fig. 1295. 
Catheter for applying nitrate of silver to the prostatic sinuses, having at one end of stylet a wrapping of cotton. 
Prostatic Abscess is one of the sequels of acute prostatitis, though I have 
met with it when all the symptoms pointed to a slow chronic inflammation. 
It may be solitary or multiple, confined to one lobe or scattered through the 
different lobes of the prostate body. The existence of abscess in the pros- 
tate may be suspected when the pain, difficulty of urination, throbbing, and 
fullness in the perineum and rectum continue beyond the usual period of 
duration of the disease, and particularly when, superadded to these symptoms, 
there occur rigors, flushes of heat, feverishness, and sweating. Our suspicions 
will receive decisive confirmation if, on introducing the finger into the rectum, 
a soft, fluctuating swelling is discovered in the gland. 
Abscesses of the prostate discharge their contents sometimes into the blad- 
der, at other times into the urethra or the rectum. If the prostatic fascia 
becomes thickened and detached from the gland, the pus may travel up be- 
tween the bladder and the rectum and finally open into the pelvis. Occa- 
sionally the abscess has taken the opposite direction and pointed slowly in 
the perineum, following the course of the middle perineal fascia. 
When the opening occurs into the rectum or into the urethra, it is an- 
nounced by the sudden appearance of thick, laudable pus in the alvine evacu- 
ations or in the urine. Whether the abscess discharges into the bladder or 
into the urethra, the pus will escape through the latter channel. But there 
should be no difficulty in determining the original seat of the opening, inas- 
much as the discharge of matter would occur only during urination, when the 
bladder had received the contents of the purulent accumulation, while if the 
communication has taken place between the prostate and the urethra the 
escape of pus will be quite independent of micturition. 
In any event, abscess of the prostate body is an unfortunate termination, 
as the urethral, vesical, or rectal openings are prone to remain as fistulse. The 
cavities which in multiple abscess exist in the gland often fail to contract, 
and continue to furnish from their walls a sufficient amount of pus to main- 
tain a constant discharge. This may continue until the entire gland is dis- 
organized. 
Treatment.-An early recognition of the abscess has an important bearing 
on the success of the treatment. If it can be detected and opened before the 
structure of the prostate has been extensively disturbed, the prospect of a 
permanent fistula will be lessened, as also will be that of pelvic complications 
from an extension of disease along the cellular tissue in the recto-vesical 
space. 
As soon, therefore, as these physical signs of bulging and fluctuation ap- 
pear, the swelling should be opened. If the abscess points towards the rec- 
tum, it should be punctured either with a long, sharp-pointed bistoury, 
slightly curved at its extremity, and conducted along the finger, or in the 
depression between two fingers introduced into the rectum, with their tops 
resting against the prominent portion of the gland ; or by means of a trocar 
and canula, the point being concealed in the latter until the prostate is reached, 
as practiced in tapping the bladder through the bowel. A. third plan for in- 
cising the abscess, and one which has the advantage of exposing the entire 
procedure to the eye, is first to introduce a cylindrical rectal speculum having 
vol. ii.-32 498 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
a large fenestra, and, after adjusting the instrument so that the swelling 
will protrude through the opening in its side, a puncture can be made into 
the abscess with a bistoury. When the bulging appears in the perineum, 
the pus should be liberated by pushing a sharp-pointed bistoury with a long 
narrow blade through the tissues of the perineum, with its back to the rec- 
tum, entering it on the raphe about one inch in front of the anus, and with a 
finger in the bowel directing it safely to its destination. When the abscess 
points towards the urethra, its diagnosis must necessarily be to a great extent 
inferential. An obstruction encountered by the catheter in the prostatic part 
of the canal would, with other concomitant signs of suppuration, be a suffi- 
cient justification for operative interference. When mature, even the con- 
tact of the end of the catheter has been sufficient to rupture the thin stratum 
of tissue which confines the pus and to allow its escape through the urethra. 
This should always be tried before employing any other measure. If it fails, 
the puncture can be made by a canula catheter armed with a trocar-pointed 
stylet. 
It is desirable, after the evacuation of an abscess, in order to prevent the 
urine, air, or faeces from entering the opening leading to the abscess and ex- 
citing inflammation and keeping up the suppuration indefinitely, to leave 
a soft catheter in the bladder for three or four days at a time, wThen the 
opening has occurred into the bladder. But when the pus has passed directly 
into the urethra or into the rectum, and the continence of the bladder remains 
unimpaired, the periodical use of the instrument will be sufficient. 
It is this difficulty with the urine that has suggested the propriety of 
emptying the abscess and at the same time furnishing a new route for the 
water until the suppurating cavity contracts, granulates, and closes. This 
is done by laying open the perineum, guided by a staff in the bladder, as 
is done in the median or the lateral operation for stone, only observing not 
to prolong the incision into the neck of the bladder, but simply through the 
prostate body. When the signs all point to a spontaneous opening into the 
bowel, it will be better to discharge the abscess by the rectum. The most 
opportune time for this procedure will be before the abscess has broken, and 
when it points in the rectum, under which circumstances the benefits likely 
to accrue will more than counterbalance the risks of the operation. 
Abscess external to the Prostate.-In consequence of severe contusions, 
or from a false passage made in inserting a catheter, inflammation is liable 
to be kindled in the loose cellular tissue wffiich connects the prostate and 
bladder with the rectum. The symptoms counterfeit with considerable ac- 
curacy those of prostatic abscess; that is, there may be retention of urine, 
with swelling and fluctuation in the rectum or perineum, and similar con- 
stitutional disturbance. In the former, however, the swelling is diffused and 
not definitely circumscribed, as in prostatic abscess, and in almost all instances 
points in the posterior or anal perineum, and distends the ischio-rectal spaces, 
as its origin is behind the middle perineal fascia. 
Early and free incisions must be made, not waiting for the pus to reach 
the surface. Any timidity or hesitation about doing this will allow extensive 
sloughing of the cellular tissue of the perineum, produce rectal fistula, and 
perhaps cost the patient his life. 
Prostatorrhoea.-This affection, first described by Professor Gross, is not 
a very common disease, but is the source of much anxiety to young men. It 
is characterized by the discharge of a consistent or ropy mucus of a grayish- 
white color, which is passed after urination and during those spasmodic con- 
tractions of the prostate which are concerned in expelling from the urethra 
the last drops of urine. Or it may occur either from the pressure of the 
faeces against the prostate body, or from the straining effort necessary to 
expel the contents of the rectum. The quantity which is passed at these 
times varies from ten or twelve drops to almost a teaspoonful. The clear, 
transparent mucus which sometimes oozes slowly from the urethra, keeping PROS TA TORRHCEA. 
499 
the external orifice of the canal constantly moist, and which is referred to 
the prostate gland as its source, is a characteristic of folliculitis rather than 
of prostatorrhcea. The effect of this discharge is peculiarly depressing to 
tbe mind of the patient, who imagines, to use his own expression, that he 
is losing his semen, and that it will be followed by a total loss of sexual 
power. It is not at all uncommon to meet with cases of this nature in which 
the mind of the patient has become so thoroughly occupied with imaginary 
anticipations of evil that he has been rendered alike incapable of attending 
to business or enjoying the pleasures of society. 
Diagnosis.-The only affections with which prostatorrhcea can be con- 
founded are gleet, spermatorrhoea, and cystitis. In gleet the discharge is 
either muco-purulent or purulent, while in prostatorrhcea it is grayish white 
and free from admixture with pus. In the former disease, moreover, there 
is always a history of a previous gonorrhoea, which is not a necessary ante- 
cedent to prostatorrhcea. The most decisive differential test between the 
latter affection and spermatorrhoea is that furnished by a microscopic ex- 
amination of the fluid, which in the latter contains a large number of sperma- 
tozoa, while in prostatorrhcea very few can be detected. In cystitis, urine 
which is passed at first cloudy, on standing for a short time deposits a heavy 
muco-purulent sediment; there are also frequent micturition, and more or 
less pain, none of which symptoms belong to prostatorrhcea. 
Causes.-The causes of prostatorrhcea are almost invariably masturbation 
or sexual excess. It is more particularly a disease of young unmarried men. 
The symptoms attending the affection scarcely warrant the assumption of 
there being any inflammatory element present, but rather point to a super- 
sensitive state of the excito-secretory nerves of the prostate body, favoring 
passive congestion of its vessels. 
Prognosis.-Though free from all danger to life, prostatorrhcea is an ob- 
stinate affection, requiring often months, or even years, for its cure. 
Treatment.-Much will have been accomplished towards a cure if the mind 
of the patient can only be dispossessed of the evil spirit of despondency which 
clings to him with such relentless pertinacity, and it is our first duty to exorcise 
this demon by assuring him of the perfectly harmless nature of the malady; 
or, if this will not answer, by changing the mode of assault and shaming 
him for his pusillanimity and want of manliness. The mind should next be 
interested in pure and entertaining books if the patient is a man of leisure, 
and all conversation, company, and amusements which are calculated to ex- 
cite or foster sensual thoughts must be avoided. 
Nothing can be more unfortunate than for a patient suffering from pros- 
tatorrhoea to have no employment. The remedies to be administered are 
those calculated to improve and invigorate the general health, among the 
most valuable of which are iron, quinine, strychnia, and cod-liver oil. All 
fecal accumulation must be avoided; and hence the necessity of keeping the 
bowels regular. 
At night, if the patient suffers from lascivious dreams or nocturnal emis- 
sions, a dose of bromide of potassium and a pill of extract of belladonna may 
be given. Not the least important element in the management of this affec- 
tion is the use of cold baths; the hip-bath is to be preferred, and this should 
be used every evening, the patient sitting for twenty minutes in the water 
before going to bed. The soft parts over the sacrum, hips, and perineum 
should be well flagellated with a muscle-beater for ten minutes. All highly- 
seasoned or stimulating food, all alcoholic drinks, smoking, and sexual in- 
dulgence, must be scrupulously avoided. 
Hypertrophy of the Prostate Body, 
Hypertrophy of the prostate is an enlargement referable to an excessive 
nutrition of its anatomical components, altogether independent of inflamma- 
tory changes. This change is essentially a senile one, being rarely seen under 500 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
fifty years of age, and the more remarkable from the fact that at this time 
of life, when the forces of growth have culminated in all other parts, they 
should assume inordinate activity in the prostate. The enlargement may be 
centric or eccentric,-that is, the body may grow in size in the direction of the 
urethra and bladder or towards the rectum. The hypertrophy may affect a 
single lobe, but more frequently the entire body. Its bulk varies from the 
size of a walnut to that of a goose-egg. I have 
seen the prostate over three inches in trans- 
verse diameter. As it increases, the shape of the 
gland is changed, its antero-posterior diameter 
is increased, and its body, when the hyper- 
trophy is general, assumes a globular appear- 
ance. (Fig. 1296.) The effect of such an en- 
largement is to elongate the prostatic portion 
of the urethra, as well as to alter its form and 
lessen its capacity. 
When the hypertrophy is chiefly limited to 
one of the lateral lobes, the direction of the 
urethra will deviate from a straight course, 
assuming an angular position with reference 
to the bladder, towards the right or towards 
the left of the median line, according to the lobe 
affected. When the middle lobe is the subject 
of the hypertrophy, it usually projects upward 
into the mouth of the bladder, and as it in- 
creases in magnitude becomes somewhat pedun- 
culated, imparting an angular curve to the 
urethra, the vertex being upward. 
Various other outgrowths of the prostate are 
occasionally witnessed, in which two or more 
mammillary masses, often somewhat pedunculated, may rise from the floor 
of the neck or from one of the lateral lobes and project into the mouth of 
the bladder. 
Frequency.- While hypertrophy of the prostate is often met with among 
aged persons, there is no doubt that its frequency has been greatly over-esti- 
mated. In 312 examinations made by Dr. John W. Lodge, 246 were found 
to be normal, 5 atrophied, and 61, or 19.5 per cent., hypertrophied. The per- 
sons examined varied in age from forty to one hundred, and, being inmates of 
the Philadelphia Almshouse, belonged to a class in whom this affection might 
naturally be expected. Sir Henry Thompson and Dr. Messer have prosecuted 
similar inquiries, the result of their labors showing about 32 percent, of those 
examined to have had slight hypertrophy and 12 per cent, marked enlarge- 
ment sufficient to cause more or less inconvenience. In 115 persons exam- 
ined by Professor Dittell, 18 had hypertrophied prostates and in 36 the body 
was atrophied. I have myself made many similar examinations, and can 
confirm the infrequency of hypertrophy; but the percentage of atrophy, I 
think, is much over-estimated. The sense of touch is a very deceptive test 
in determining the fact of the gland being under size. I have a considerable 
number of bladders which were removed from old persons who died from 
various diseases, and in all of them the prostates before being cleaned from 
their adventitious connections would have been regarded as atrophied, but, 
after careful dissection, are shown to be entirely normal. The weight of the 
healthy prostate is about five drachms, its antero-posterior diameter aver- 
aging three-quarters of an inch, and its transverse and vertical diameters 
one inch. 
Pathology.-The anatomical components of the prostate body are smooth 
muscular fibres, connective tissue, and glandular tissue. The hypertrophy 
is essentially an excessive development, chiefly of the muscular fibres and of 
the connective tissue, which normally constitute almost three-fourths of its 
Fig. 1296. 
General enlargement of the prostate 
body.-From a preparation in the Mu- 
seum of the College of Physicians. HYPERTROPHY OF THE PROSTATE BODY. 
501 
substance. The glandular tissue undergoes no increase,-in fact, is rather 
atrophied, and, in cases of uniform hypertrophy, it may be entirely destroyed, 
though in the nodular or irregular form 
of prostatic hypertrophy there is a real 
glandular hypertrophy, which includes, 
of course, a multiplication of the tubuli 
as well as increase of the epithelia. In 
addition to the general and the irregular 
enlargement of the prostate, it is quite 
common to find one or more small tumors 
projecting from its substance (Fig. 1297), 
and which may without difficulty be shelled 
out of their bed. 
These growths, which vary in size from 
that of a pea to that of a pigeon-egg, and 
are very dense and elastic when laid open, 
are seen to consist, like the prostate itself, 
of muscular and fibrous tissue, with very 
little, however, of the glandular element. 
They are not peculiar to the hypertro- 
phied prostate; they will often be found 
in a gland which is in all other respects 
sound. 
This tendency to the development of 
musculo-fibrous growths in the substance 
of the prostate is so much like that which 
occurs in the uterus of the female about 
the period of the menopause, that the ana- 
tomical analogy between the two organs appears to be well sustained. 
Symptoms.-One of the earliest symptoms which betoken prostatic hyper- 
trophy is increasing frequency of micturition, with a little detention in 
starting the stream. This may continue a long time without causing any 
particular inconvenience or even awakening the least suspicion of anything 
being wrong. As with increasing years there usually comes a growing desire 
to urinate with greater frequency, the urination is referred to what is believed 
to be the necessary attendant of senility. Along with this desire to micturate 
there is a noticeable diminution in the force with which the stream escapes 
from the urethra, and an increased effort is necessary to eject it, especially 
at the commencement of the act. As the disease advances, the calls to urinate 
become more urgent, the patient is compelled to rise repeatedly during the 
night, and his sleep is therefore broken and disturbed. There is a feeling of 
fullness, weight, and discomfort in the perineum and bowel, which often com- 
municates the sensation of a half-completed alvine dejection. Pain when 
present is not uniform in its location, being sometimes felt in the glans penis, 
sometimes along the whole tract of the urethra, and at other times seated 
at the neck of the bladder. As the encroachment upon the urethra progresses, 
the trouble experienced in dislodging the urine increases. It is some time 
before it begins to pass, and then slowly and only after forcible and protracted 
muscular efforts, which barely answer to impel the stream sluggishly along 
its channel, when it falls at the feet instead of being projected in a curved jet 
from the meatus. The same difficulty that is realized in starting the urine 
is felt in completing the act. The final propulsive contractions, which nor- 
mally are so efficient in ejecting the last drop and promptly clearing the 
canal of all moisture, are so impaired and imperfect that a portion of water 
remains in the urethra, gradually dribbling out, so that the clothes of the 
patient become wet and soiled. 
With this growing muscular insufficiency, and the massive obstruction at 
the mouth of the bladder, a certain amount of water remains in the dependent 
part of the bladder. This, if not detected, gradually accumulates, only the 
Fig. 1297. 
Multiple tumors in the prostate and projecting 
into the mouth of the bladder.-From a specimen 
in the Museum of the College of Physicians. 502 
INJURIES AND DISEASES OF THE GEN ITO-URINARY ORGANS. 
overflow escaping, until the organ becomes increased in size; and finally, as the 
distention increases, the urine begins to dribble away, especially during sleep, 
when the volition of the patient no longer operates to control the neck of 
the bladder. It is this apparent incontinence, which often goes by the name 
of vesical paralysis, which is liable to deceive the practitioner, who, unable 
to reconcile a constant flow of urine with the idea of retention, fails to re- 
lieve the accumulation by the use of the catheter. In addition to these signs, 
the straining which is required to expel any part of the contents of the bladder 
often occasions a mucous discharge from the urethra, prolapse of the bowel, 
hemorrhoids, swollen testicle, and sometimes hernia. In some cases the stools 
are passed in a flattened form, owing to the action of the muscles of the bowel 
and the resistance of the hypertrophied prostate, which encroaches on the 
cavity of the rectum. 
The urine in time undergoes important changes. The portion retained in 
the bas-fond of the organ decomposes, and this reacting on the vesical mucus 
soon excites cystitis; the secretion is not lessened in quantity, but is rather in- 
creased above the normal amount. When passed from the bladder it is thick, 
cloudy, usually strongly alkaline, but sometimes acid, and deposits on stand- 
ing a ropy mucus mingled with phosphates, and possibly discolored with 
blood, which becomes exceedingly offensive from the sickening odor which 
it emits. 
With the progress of the local trouble the health of the patient becomes 
deeply implicated; a slight exposure to cold or any irregularity in the ordi- 
nary habits of living is sufficient to aggravate all the local symptoms, by ex- 
citing an increased congestion of the prostate and bladder, accompanied with 
fever. And, to add to the severity of his sufferings, an attack of retention 
may occur at the same time. As is the ordinary history of chronic incurable 
maladies, the disease, with occasional respites, steadily advances. One acute 
attack follows another with increasing frequency, until, worn out by loss 
of rest and by severe, often agonizing suffering, the scene is closed from sheer 
exhaustion, ulceration of the bladder, or perhaps uraemic poisoning. 
Diagnosis.-Should any doubt remain with reference to the existence of 
prostatic hypertrophy after recognizing such a symptomatic portraiture as 
has been drawn, a digital examination will remove all obscurity or uncer- 
tainty in the matter. The prostate body is readily felt through the rectum, 
and its outline and magnitude can be accurately determined with the finger 
in the bowel, wThen passed in different directions over its surface. The ex- 
amination should be made with the patient on his back, with the limbs 
drawn upward and separated, and may often be rendered more satisfactory 
if conducted with a catheter in the bladder. The physical examination 
through the rectum may, however, in centric hypertrophy of the prostate, 
fail to communicate the desired information, as the growth is inward and 
may cause no peripheral alteration of the body from its normal size. We 
must, then, when the rational signs of prostatic enlargement are present, 
proceed carefully to eliminate by exclusion the probability of stricture and 
stone, wThich most assimilate the disease. This can be done only by an in- 
strumental exploration of the urethra and the bladder, and a careful inquiry 
into the history of the patient. 
When an obstruction is encountered only at the neck of the bladder, re- 
quiring a sudden and abrupt change in the direction of the instrument to 
surmount it, and when the subject is between fifty and sixty years of age, 
and there are present no characteristic signs of stricture or urinary calculus, 
everything points to the existence of internal or centric hypertrophy of the 
prostate. 
The evil effects of prostatic hypertrophy are experienced in different ways: 
1st. The flow of urine is impeded, which is the most common and distress- 
ing result of the disease. This is in consequence of the obstructive mass 
planted at the mouth of the bladder, and also arises from the change in 
the direction and size of the urethra, which has already been described, and HYPERTROPHY OF THE PROSTATE BODY. 
503 
which varies according as the median or the lateral lobes of the prostate are 
affected. 
2d. The bladder, in consequence of the difficulty experienced in expelling 
its contents, invariably suffers in unrelieved cases of prostatic enlargement. 
The severe, frequent, and partially fruitless efforts made by the walls to 
dislodge the urine induce hypertrophic enlargement of the bladder and of 
its muscular coat, the fasciculi of which give to the interior of the organ a 
ridged or columnar appearance. The same influence which is at work to 
produce the thickening of the muscular fibres is influential in causing lateral 
pouches or sacs to form, by the protrusion of the less resisting parts of the 
bladder between the muscular ridges. A transverse ridge or bar sometimes 
forms across the surface of the trigonus vesicse, which may also oppose a bar- 
rier to the escape of urine. It is caused by hypertrophy of the transverse 
muscular fibres which cross this part of the bladder. It owes its chief im- 
portance to the notice which it has received from Mr. Guthrie. It is not, 
however, always peculiar to hypertrophy of the prostate, but may occur 
entirely independent of this disease, and under any circumstances is an ex- 
ceptional condition. In addition to this muscular bar, two others are occa- 
sionally seen in the neck of the bladder, both consisting of hypertrophied 
submucous tissue. One of these appears immediately over the middle lobe of 
the prostate, and the other, when present, between the middle and one of the 
hypertrophied lateral lobes of that body. In singular contrast with the en- 
largement of the bladder is another change, in which the organ becomes con- 
tracted and its cavity greatly diminished. This is likely to occur in cases in 
which, though the prostate may be very large, the hypertrophy does not in- 
volve the median lobe and is symmetrical in the lateral lobes, so that no ob- 
struction rises between the urethra and the mouth of the bladder. The 
freedom with which the urine escapes in this condition does not admit of 
residual collections, and, consequently, there is little excess of mucus; and 
the intolerance of the bladder to the pressure of water tends both to 
diminish its capacity and to cause a centric hypertrophy of its muscular 
walls. 
Cystitis is another of the sequels of enlargement of the prostate, and 
originates from the influence of decomposed residual urine on the mucous 
membrane, assisted by the constant congestion of the latter, produced by 
inordinate increase of function in the muscular walls of the bladder. 
3d. The excessive supply of mucus which is excited by the action of the 
ammonia resulting from the decomposition of the urea may, in connection 
with phosphatic depositions of the urine, crystalline or amorphous, form 
little masses sufficiently consistent to serve as the nucleus for a stone. The 
conditions which are particularly favorable to such formations are found in 
the sacculated bladder. The pouches, from the manner in which they are 
formed, being deficient in muscular fibres, allow the little pools of water 
which they contain to remain and to deposit those materials which form the 
bases for calculi. 
As in stricture and cystitis of long standing there is a tendency in the 
ureters and kidneys to become implicated, so in hypertrophy of the prostate 
these organs rarely escape unharmed : varicose dilatations of the ureter, with 
local hypertrophy of its muscular walls, and abscess, cysts, and other inflam- 
matory changes of the kidneys, are the morbid alterations of structure 
likely to ensue. 
Treatment.-Senile hypertrophy is an incurable malady, yet one which 
can be greatly palliated, and in which the patient can do a great deal towards 
his own comfort. He must make up his mind to pursue a rigid course of 
systematic living, from which under no circumstances should he be tempted 
to deviate; his food must be plain, consisting largely of vegetables and milk. 
Meat should be taken in moderation ; all stimulants are to be eschewed, as well 
as every acid fruit, though lemonade is sometimes advantageous. Riding on 
horseback or in carriages over rough roads must be avoided, and when in the 504 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
house it is wise to recline rather than to sit erect. The body, bowels, and 
feet are to be preserved warm and dry with scrupulous care, the bowels to be 
maintained in a regular condition, and all sexual excess avoided. These prelim- 
inaries arranged, the next important step is to provide against the evil effects 
of the mechanical obstruction to the passage of the urine. Unfortunately, the 
prejudice which exists against the use of the catheter, even among medical 
men themselves, operates greatly to the disadvantage of the patient: he de- 
lays and suffers, and suffers and delays, as long as water can be passed at all, 
under the impression that the employment of an instrument is a last and 
extreme resort, when in truth it is our sheet-anchor, first and last. The mo- 
ment, therefore, that it is discovered that a portion of water remains in the 
bladdei* which cannot be displaced by the voluntary efforts of the patient, 
that moment is the catheter indicated in order to prevent the ill effects re- 
sulting from the retention of residual urine. 
The frequency with which the cathetei* should be used must depend on the 
completeness with which the bladder is emptied. It may be required once, 
twice, or even three times in the twenty-four hours. 
A patient will often be able to empty the bladder by resting, during urina- 
tion, on the elbows and feet when it cannot be completely done in the ordi- 
nary position. A like success is sometimes achieved by turning on one or 
other of the sides; and I have a patient who has been able to avoid the use 
of the instrument fbi* a week at a time by placing one foot on his bath-tub 
and leaning over to the opposite side with the supporting limb semiflexed. 
The tolerance of the urethra and bladder to instrumentation must also 
have its weight in regulating the number of catheterizations. If the passage 
becomes irritable under the operation, it will be better to make the intervals 
as long as possible consistent with the safety of the bladder. A prominent 
physician of Philadelphia told me that he had drawn his water regularly 
three times a day for seventeen years, and that, though engaged in an ex- 
tensive practice during that time, he had enjoyed life as much as any of his 
medical friends. 
The patient should be early taught how to pass the instrument himself. 
The soft catheter is always to be preferred when it can be passed into the 
bladder. That of Mercier (Fig. 1298) is admirably adapted for the purpose ; 
or the ordinary gum catheter having a stylet with which to preserve the 
Fig. 1298. 
Fig. 1299. 
Fig. 1300. 
Catheters, gum and metallic, suitable for use in cases of enlarged prostate. 
short, abrupt bend at its vesical extremity, which is so often required to 
mount over the prostatic eminence at the neck of the bladder, may be used. HYPERTROPHY OF THE PROSTATE BODY. 
505 
(Fig. 1299.) The same curve, approximately at least, will be demanded in 
the silver catheter when that instrument is employed. (Fig. 1300.) 
A vast amount of empirical experimentation has been practiced in the use 
of various remedies for the reduction of hypertrophy of the prostate. Iodide 
of potassium, mercury, buebu, ergot, and other drugs have been extolled at 
various times, as also suppositories of iodine and injections of ergot into the 
substance of the gland, but have failed to command the confidence of the 
profession. Operations of crushing by means of the lithotrite, when the 
growth is directed inward and sufficiently pedunculated, have been sug- 
gested,-procedures which perhaps would be better done on the dead body, 
if done at all. Compression applied to the prostate through the rectum by 
hydrostatic and other means has also had its advocates, but has not yielded 
any practical results. 
The constitutional treatment will be best carried out by the use of the 
tincture of the chloride of iron and quinine, and in addition opium sup- 
positories when much general irritation exists. 
A patient laboring under enlarged prostate is liable, as a result of exposure 
to cold or dampness, or from some other indiscretion, to suffer from acute 
attacks in consequence of the resulting vascular engorgement of the gland, 
the swelling from which blocks up the urethra and the mouth of the bladder 
so as to produce complete retention, and this generally requires the assistance 
of the surgeon for its relief. In the use of the catheter, in addition to giving 
the instrument the sharp curve, it will generally be necessary to guide its 
point over the obstruction by the finger inserted into the rectum. A few 
leeches to the perineum and a hot hip-bath will materially assist in removing 
the swelling and opening the way again for the voluntary discharge of. the 
urine. 
Prostatic Calculi.-Calculi are occasionally met with imbedded in the 
substance of the prostate body. They may exist singly or in great numbers, 
are quite hard, and vary in size from that of a grain of sand to that of a pea. 
Their color is not uniform, being sometimes white and at other times yellow 
or brown. They are occasionally so closely packed together that the cyst-like 
walls of separation become absorbed and the calculi rest together at their 
borders, having a pavement-like appearance, or constituting a figure like that 
presented by the back of a tortoise. 
These bodies are most probably formed on a nucleus of inspissated mucus. 
In the ducts and follicles of the prostate gland of the adult there exist in 
great numbers at all times minute bodies, the nature of which is not entirely 
understood. They are believed by Virchow to be composed entirely of organic 
matter. Occupying the position which they do, they probably consist of the 
inspissated secretion of the gland-tissue of the prostate, as occurs frequently 
in the biliary and salivary ducts as a precedent condition of biliary and 
salivary concretions. The addition of the carbonate and phosphate of lime 
to these bodies, by increasing their bulk, gives rise to local irritation and 
favors the further deposition of the inorganic salts of the prostatic secretion, 
until they become of sufficient magnitude to occasion great suffering. 
Their composition, according to Wollaston, is phosphate of lime, carbonate 
of lime, and animal matter; 84 per cent, of the first, J per cent, of the second, 
and 15 per cent, of the last. When small, they may not cause any great 
uneasiness, but when they attain suffi- 
cient size to encroach upon the urethra 
or mouth of the bladder, they are ca- 
pable of developing all the symptoms 
which characterize enlarged prostate. 
Diagnosis.-When these concretions 
acquire considerable bulk, they may 
be felt by an examination with the 
finger introduced into the rectum. Should they project into the urethra or 
bladder (Fig. 1301), they might readily be mistaken for urinary calculi. 
Fig. 1301. 
Prostatic calculus. 506 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Unless, however, they can be detected by digital tact through the walls of 
the bowel, the recognition of their presence must be plainly inferential. 
Treatment.-As long as these calculi occasion no great suffering, nothing 
more than palliative treatment will be required-avoiding everything which 
is calculated to add to the local irritation, as horseback-riding, fecal accu- 
mulations in the rectum, and acidity of the urine, using, when the rest 
is much broken, a rectal suppository of opium at bedtime. These calculi, 
when they attain any considerable size, may, by ulceration, find their way 
into the urethra, the bladder, or the rectum. When the suffering attending 
their presence becomes sufficiently important to justify operative measures, 
a staff should be introduced into the bladder and the perineum and prostate 
laid open as in median lithotomy,-not, however, extending the incision into 
the bladder,-and all the concretions which can be discovered should be 
extracted. 
Cheesy Deposits in the Prostate do not exist independently of similar 
deposits in other structures, as the bladder, kidneys, testes, and seminal 
vesicles. They are occasionally met with in strumous subjects. The degen- 
eration commences in the glandular portion of the prostate, and the deposits, 
which are peri-tubular, soften down, completely disorganizing its structure, 
and causing numerous abscesses, which discharge, leaving cavities resembling 
the vomicae in tubercular disease of the lungs. This degeneration may occur 
at almost any period of life, though no cases have been observed earlier than 
eleven years of age. 
Symptoms.-If, in a scrofulous patient, irregular masses can be felt over 
the surface of the prostate, with indurated, irregular prominences in the 
vesiculae seminales, the existence of this cheesy degeneration is rendered 
highly probable. 
As this disease is only one expression of a deep constitutional vice, the 
prognosis is necessarily unfavorable. 
Treatment.-The remedies which are indicated are such as are calculated 
to improve the nutrition, as cod-liver oil, iodide of iron, and good food. 
Cancer of the Prostate is almost invariably secondary to carcinoma- 
tous disease in other parts of the body, and even then is exceedingly rare. 
The medullary or encephaloid variety appears to be the most common, though 
the scirrhous, melanotic, and colloid forms of the disease are said to have 
been observed. At no period of life is the prostate exempt from this ma- 
lignant degeneration. The disease sometimes previously begins in the epi- 
thelial lining of the testicle. 
Symptoms.-There are no symptoms which reveal with any certainty the 
existence of cancer of the prostate, but there would be plausible grounds for 
suspecting its presence if, in connection with medullary disease elsewhere, 
and with frequent and painful urination, there should be found irregular, soft 
projections over the surface of the prostate, when examined with the finger 
in the rectum. 
Treatment.-Nothing can be done for the permanent relief of cancer of 
the prostate. The symptoms may be palliated by the use of the catheter 
when the obstruction interferes seriously with the passage of the urine, 
and by using opium suppositories and alkaline drinks. Tonics of iron, of 
arsenic, and of quinine, with proper food, will be required to keep up the 
strength. 
Cysts, in the strict sense of the term, are seldom, if ever, found in the pros- 
tate. The nearest approach to affections of this kind is seen in the dilata- 
tion of the ducts and acini of the follicles by concretions formed from the 
prostatic secretion, and in the smooth-walled cavities which formed the bed 
for calculi or remain after the discharge of an abscess. 
Hemorrhage.-The prostate, though not supplied with vessels of any 
magnitude, may nevertheless be the source of considerable hemorrhage, 
which may originate in an unusual plethora of its vessels, or in consequence 
of the rude use of instruments in the urethra. RETENTION OF URINE. 
507 
Treatment.-Rest in the recumbent position, cold applied to the perineum, 
and full doses of ergot are the remedial measures to be adopted. 
Retention of Urine. 
The causes which give rise to retention of urine are mechanical, patho- 
logical, congenital, psychical, miasmatic, and therapeutical. 
Symptoms.-Retention of urine is peculiarly distressing. When complete, 
there is a sense of fullness or distention experienced in the hypogastrium; 
the patient has a constant desire to micturate, accompanied by pain and vesi- 
cal tenesmus; and as the accumulation increases the extreme mental dis- 
tress, anxiety, and nervous excitement become almost uncontrollable. The 
local signs of urinary accumulation are a circumscribed swelling in the hypo- 
gastric region, with corresponding percussion dullness, and a fullness which 
may be felt in the inferior part of the pelvis by introducing a finger into 
the rectum or the vagina. In incomplete retention, there may be constant 
dribbling of urine, or the latter may escape at short intervals for a few 
moments in a very fine stream. 
If the case is allowed to progress without being relieved, constitutional 
symptoms arise of an alarming character. Rigors occur alternately with 
flushes of heat, and are followed by hot skin, feeble and frequent pulse, a 
dry, dark tongue, with a urinous odor emanating from the breath and skin, 
accompanied by extreme exhaustion, and, finally, hiccough, wandering, and 
stupor, which betoken the near approach of death, a termination which 
rarely occurs earlier than the seventh or eighth day. 
Diagnosis.-The signs of retention are so characteristic and obvious that it 
seems almost incredible that any medical man should fail to recognize the true 
condition; and yet I have many times witnessed the most egregious errors 
committed in this matter,-some, I regret to say, which cost the patients their 
lives. One of the most common sources of error-that which is most likely 
to lead an inexperienced man astray-is the constant dribbling of urine which 
is often present in retention. This, which is the overflow from distention, is 
supposed to be inconsistent with the presence of a serious accumulation, and 
hence the failure to realize the mischief which is going on. The records of 
surgery are full of mistakes in diagnosis with regard to urinary retention. It 
has been confounded with ascites, ovarian dropsy, pregnancy, pelvic tumors, 
and abscess. 
The use of the catheter constitutes an easy method of clearing up all 
obscurity, and renders a mistake inexcusable. 
In large accumulations the bladder rises from the pelvis, and becomes 
very prominent above the pubes. It may reach some distance above the 
umbilicus,-even, it is alleged, to the diaphragm. The effect of such a change 
of position is to put to a severe strain the reflections of the pelvic fascia, 
which serve as the vesical ligaments, and to elongate the urethra so that a 
catheter considerably longer than the ordinary instrument may be required 
in order to reach the bladder. When the distention is great it will be best 
to draw the water slowly, so as to give time for the walls of the organ to 
recover their contractility, or to remove the accumulation at two different 
catheterizations, a few hours apart. Neglect of this precaution has been fol- 
lowed by vesical hemorrhage, from the loss of support to the vessels of the 
mucous membrane. Even death from syncope has ensued on the sudden 
abstraction of a large collection of urine. 
Fatal terminations of retention can rarely be attributed to rupture of the 
bladder, though its walls, thinned under the effects of mechanical distention, 
finally become inflamed, softened, and even gangrenous. As long as the valvu- 
lar arrangement which exists at the entrance of the ureters remains unim- 
paired, the damage is confined to the bladder; but when those openings begin 
to yield, the urine is forced back, and the ureters become dilated. The typhoid 508 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
symptoms which are soon developed in neglected retention are due to the 
constituents of the renal secretion re-entering the blood and rendering it 
unfit for the purposes of nutrition. 
The amount of urine which the bladder is capable of containing without 
serious lesion is almost incredible. I am certain that I have in two instances 
removed not less than two gallons. Boyce mentions the case of a patient 
who suffered from retention as a consequence of paralysis, and from whose 
bladder after death eighty pounds of urine were removed, which would be 
equivalent to ten gallons by measure. 
Retention from Primary Mechanical Causes is occasionally met with, 
the most common being that which arises from coagula of blood within the 
bladder, impaction of the foetal head in the cavity of the pelvis, pressure of 
the gravid uterus, or large fecal accumulations in the rectum. 
When, in consequence of renal or vesical hemorrhage, blood-clots accu- 
mulate in the bladder, obstructing the flow of urine, it is well to wait a short 
time before resorting to instrumental interference. The urine may find its 
way through the coagula, and be discharged voluntarily, or may rise to 
the surface on their subsidence and be easily drawn off. It is also capable 
of dissolving the clots, to some extent, so that they can be expelled in 
fragments. 
When it becomes necessary to interfere in consequence of the extent of 
the accumulation, the ordinary catheter will prove almost useless, as the 
small openings at its end are soon occluded by the intrusion of small masses 
of coagula, which prevent the entrance of the urine. An instrument having 
at its vesical extremity two large eyes, one on each side, and not directly 
opposite each other (Fig. 1302), will serve a better purpose. 
Fig. 1302. 
Author's blood catheter. 
This catheter having been introduced into the bladder, should the water 
not flow, the nozzle of a large syringe may be fitted to the extremity, and a 
column of air or tepid water forced through its canals, by which the clots 
can be displaced. The syringe can also be used as an exhauster, by drawing 
the piston back, thus favoring the escape of both blood and urine. 
Or a catheter may be used like that of Professor Gross, in which the 
opening is situated at its end, which is closed by an obturator. The latter 
is withdrawn after the instrument enters the bladder. When the reten- 
tion is due to pressure either from the gravid uterus or from the foetal head, 
and demands immediate relief, the difficulty roust be overcome by pushing up 
the one or the other and introducing the catheter. When fecal accumula- 
tions in the rectum prevent the passage of the urine, as will frequently hap- 
pen in old persons deficient in muscular expulsive power, the bowel will 
require to be cleared by injections or by the scoop. 
The retention may be complete or partial. In the first not a drop of urine 
escapes; in the second there may be constant dribbling or the frequent 
passage of a small stream. 
Pathological Causes of Retention.-Under this head are included stric- 
tures of the urethra, or the congestion and spasm incident to their presence, 
hypertrophy of the prostatic body, concussion of the brain and spinal marrow, PATHOLOGICAL CAUSES OF RETENTION. 
509 
paralysis, perineal abscess, uterine growths, exostosis of the pelvic bones, 
cysts, and spasm. 
Treatment.-When the retention arises from a congested stricture, there 
is frequently associated with the latter more or less muscular spasm. To 
ascertain definitely the date of the retention, the patient should be pointedly 
interrogated. A person laboring under stricture may suffer from partial in- 
ability to pass the urine for several days before complete stoppage occurs, 
or he may have been deeply intoxicated, and, therefore, not sensible of the 
duration of the accumulation. When satisfactory information cannot be ob- 
tained from the patient, the surgeon must be guided in his decisions by the 
size of the vesical tumor. 
If the case is very recent, there is no necessity to rush precipitously to the 
use of the catheter. On the contrary, it may be desirable to delay for a short 
time all operative interference, until the local irritation and swelling have 
been somewhat subdued. Much may be done in such a case by restoring the 
morale of the patient, assuring him that there is no necessity for alarm, that 
all apprehensions of rupture are groundless, and that relief will be obtained 
in a short time. If an attempt to pass an instrument is made too soon, it is 
liable to provoke an increased degree of spasm, and thus add to the existing 
obstruction. 
A hot hip-bath, a few leeches and hot fomentations applied to the perineum, 
and an injection of laudanum and tincture of belladonna (laudanum, gtt. xl; 
tinct. belladonna, gtt. xx) thrown into the bowel will next be indicated. 
Frequently nothing more is required ; in two or three hours the swelling 
begins to subside, the neck of the bladder relaxes, and the patient is pleas- 
antly surprised to find that now a few drops of water can be passed, the 
amount gradually increasing little by little, until finally a fair stream is 
attained, and the case terminates without catheterization at all. Should this 
result, however, not follow the measures which have been detailed, or if the 
retention has already existed for eight or ten hours, it will not do to procras- 
tinate. The time does not preclude the hip-bath and an anodyne injection 
or suppository; these will still be useful as aids in the work of relief; but 
more is demanded. The catheter must be passed. 
The probabilities of success will be greatly increased by the use of an an- 
aesthetic. After the patient is brought under the influence of ether, a small 
catheter (No. 4 or 5) should be passed down the urethra, until the stricture 
is encountered. Probably, after a little detention and after careful manipu- 
lation, the obstruction will be cleared, the bladder reached, and the urine 
removed. Under such circumstances, it will be well to tie the instrument 
in and allow it to remain for twenty-four hours, when the attack will have 
ended. 
Should the surgeon be foiled in his attempts to pass the coarctation, a long, 
soft, filiform bougie may be next employed, and, if he succeeds in getting 
beyond the contraction, it can, by being passed through the catheter, be used 
as a guide for the safe conduct of the latter into the bladder. 
Prostatic Enlargement.-Next to stricture, enlargement of the prostatic 
body constitutes one of the most common causes of urinary retention, the 
subjects being in the main old men. The obstruction which in these cases 
interferes with the discharge of the urine may be a permanent one, or it 
may only arise when, in consequence of cold or the abuse of stimulants, the 
gland becomes swollen. The difficulty which is encountered by the catheter 
is at the neck of the bladder, from the acute deflection of the canal. 
Generally in cases of this nature the soft catheter will be found most satis- 
factory, and especially the Mercier (Fig. 1298), or that with an elbow. The 
addition of this fixed point to a flexible shaft confers a mechanical advantage 
which no other instrument possesses to the same degree, and by which it can 
be made to surmount with great ease abrupt obstructions in the course of the 
urethra. It will, however, often be necessary to resort to the long English 
gum catheter, which may be used either with or without a stylet, and the 510 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
extremity of which must generally be bent to quite an abrupt curve in 
order to mount over the obstruction. Sometimes the silver catheter will 
answer a better purpose than any of the soft instruments. 
With the object of surmounting these short curves, such as are encountered 
at the prostatic body, metal catheters with flexible extremities have been 
devised, of which there are three varieties, that of Squire, of Elmira (Fig. 
1303), that of Levis, and that of the younger Gross. (Fig. 1304.) 
Fig. 1303. 
Squire's vertebrated catheter. 
Fig.1304. 
Gross's spiral catheter. 
The vesical extremity of Squire's catheter is formed by a series of metal 
imbricated caps, linked together with wire; that of Gross has a spiral coil of 
wire interposed between its shaft and extremity. Articulated instruments 
are liable to corrode and to break while being introduced into the bladder, 
which constitutes a valid objection to their use. 
When the catheter does not readily surmount the prostatic elevation, it 
can be greatly assisted in doing so by the pressure of a finger inserted into 
the rectum and acting against the instrument through the membranous part 
of the canal. The handle of the catheter in such cases will often require to 
be more depressed after the point passes beneath the pubes than in ordinary 
catheterization. When the soft catheter is used, its extremity can often be 
coaxed over the seat of obstruction by withdrawing the stylet a very short 
distance, thus increasing the curve at the end of the instrument. 
When the obstruction arises from a sudden congestion or swelling of the 
prostate, the catheterization maybe rendered less difficult by premising a hot 
hip-bath. 
Gonorrhoeal urethritis, more particularly in its later stages, is sometimes 
followed by retention, especially if there has been exposure to cold, a too 
free use of stimulants, or any sexual excess. The obstruction is located in 
the prostatic part of the canal, and is due to congestive swelling. 
Cystitis will, in rare instances, provoke retention. This may not at first 
be understood by the medical attendants, as it will probably occur in cases 
where the bladder has long been so intolerant of the presence of the urine 
that it will not retain more than a few tablespoonfuls at a time, and the pa- 
tient is, consequently, urinating every half-hour. The pain and distress when 
the neck of the bladder, from or spasm, refuses to allow the water to 
escape, are exceedingly severe, not from the amount of fluid which the bladder 
contains, but from its irritating effects on the supersensitive vesical walls. 
The catheter will usually be required for relief. 
Retention as a result of concussion is very common, and is due to a loss of 
power in the muscles, both vesical and abdominal, which are concerned in the 
expulsion of urine. If the injury has been very severe, it may after a short PR OS TA TIC ENLA R GEM ENT. 
511 
time be followed by incontinence. The catheter should be employed three 
oi' four times in the twenty-four hours until the innervation of the muscles 
returns, which, in ordinary cases, soon follows the recovery from concussion. 
When the obstruction to the passage of urine is produced by the pressure 
of a perineal abscess, the indication is to evacuate its contents, and, if this 
does not remove the disability, then to pass the catheter. 
Uterine tumors, cysts, exostoses, and other pelvic growths, which occasion re- 
tention by pressure, must be treated tentatively or radically, according to the 
feasibility of their removal. Temporary relief can often be obtained by 
changing the position of the tumor, either by digital pressure or by posture, 
when the bladder or the urethra will be relieved, for the time being, of the 
pressure. This may be necessary to the easy introduction of the catheter. 
Spasmodic retention may be either traumatic or idiopathic. The former is 
frequently seen to follow the rough use of instruments in the urethra, the 
ligature of hemorrhoids, fractures, and severe surgical operations. The latter 
arises from exposure to cold and dampness acting on a highly sensitive or- 
ganization, and producing swelling of the prostatic urethra. When the 
retention is traumatic, the catheter is generally required for relief; but when 
it is idiopathic, a hot bath, followed by an opium suppository or an enema 
of laudanum, will often render the use of the instrument unnecessary. 
Congenital causes of retention include any malformations which may pre- 
vent the escape of the urine, as an imperforate prepuce or an atresia of the 
meatus, in which case circumcision or incision will be required. 
Psychical Causes.-There are some persons who are so constituted 
that they are never able to empty the bladder in the presence of others. 
From this extreme sensibility the urine is allowed to accumulate until the 
organ becomes over-distended, when it is rendered incapable of contracting 
on its contents, in the same way that the uterine contractions are often 
prevented by a large amount of the liquor amnii. 
A gentleman who traveled frequently between Pittsburg and Philadel- 
phia was in the habit of coming to my office on reaching the latter place in 
order to be catheterizcd. The idea of entering the water-closet in the pres- 
ence of other passengers was so repugnant to his feelings that the bladder 
became helpless from over-distention. 
I have several times known persons who, under excitement, were unable 
to evacuate the bladder without the persuasion of a stream of water flowing 
in a wash-bowl. I recall also an instance in which a strong, sturdy man was 
unable to urinate without assuming the feminine position of squatting. 
Cases of a kindred character are designated by Sir James Paget as " stam- 
mering of the bladder." 
Among the psychical causes of retention is that sometimes called hys- 
teroidal, peculiar almost entirely to women. The physician who is not 
entirely conversant with these freaks may be subjected to a great deal of 
anxiety, annoyance, and loss of time by catering to the sham and drawing 
the water for a long time. In a case suspected to be of this nature a careful 
examination should be made, to learn if the eccentric behavior of the organ 
can be traced to any mechanical or other cause, when, if satisfied that none 
such exists, after drawing the urine, a repetition of the operation may be 
avoided by declining any further interference. The patient then generally 
manages to relieve the retention by her own voluntary efforts. 
Miasmatic Retention is to be inferred when the inability to urinate occurs 
periodically, in which case quinine, arsenic, and piperine are the remedies 
indicated during the intervals between the paroxysms, and the catheter 
should be used to relieve the immediate urgency. 
Therapeutical Retention.-There are certain drugs which, from their 
tendency to cause irritation at the neck of the bladder, produce retention 
of urine, by creating congestive swelling and spasm at the urethro-vesical 
opening. Such are cantharidcs and spirit of turpentine. A hot hip-bath 
and an anodyne enema, with mucilaginous diluent drinks, soon overcome the 512 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
difficulty. Should a voluntary evacuation of the urine not follow their use, 
a soft catheter may be employed. 
Forced Catheterization. - In difficult cases, where it has been found 
impossible to reach the bladder by ordinary measures, there remain the alter- 
natives of forced catheterization or tapping the bladder. By forced cath- 
eterization the instrument, after having reached the neighborhood of the 
bladder, is pushed onward by main force and in the direction of what is 
believed to be the proper course until the bladder is reached. This is most 
rash, dangerous, and culpable surgery. The point of the catheter is as likely 
to pass into the recto-vesical space or into the pelvis as into the bladder; or 
if it reaches the latter it will probably be by some circuitous route, and the 
dangers of urinary infiltration, abscess, and fistula will be scarcely less than 
those arising from the retention. 
When, therefore, the alternative is presented, there can be no doubt about 
the propriety of tapping; though, I repeat, the operation will seldom be 
required in the hands of a skillful surgeon. 
While making this statement, it must not be concealed that there are many 
excellent practitioners who have had little experience in dealing with intrac- 
table strictures and the urinary complications which so often attend their 
presence, and in such cases it would bo unreasonable to expect that address 
and success in the use of the catheter wdiich are attained by the hospital 
surgeon. Hence the dogmatism which sometimes characterizes surgical 
writings with reference to the uniform feasibility of catheterization in all 
cases of retention may operate not only to the injury of a patient, by in- 
ducing the less skillful to persevere too long in unsuccessful efforts with the 
instrument (when the aspirating trocar could be successfully substituted), 
but may also tend to expose the reputation of a medical man to unjust reflec- 
tions and censure. 
Tapping the Bladder.-The bladder may be opened above the pubes, 
through the pubic symphysis, beneath the pubes, through the perineum, and 
through the rectum. 
The simplest plan, and one requiring very little skill, is the supra-pubic 
operation with a Dieulafoy aspirating trocar. The bottle being exhausted of 
its air, a capillary trocar and canula are pushed into the distended bladder 
two or three inches above the pubes, exactly in the median line, or linea alba, 
and carried onward until all resistance ceases. The canula being now con- 
nected with the flexible tube of the bottle and the trocar withdrawn, the 
urine will flow into the receiver. 
The operation can be repeated several times if necessary; though it is 
always proper, before resorting a second time to aspiration, to make another 
effort at catheterization. 
In the formal operation of the supra-pubic tapping the patient is placed in 
the recumbent position and the hair removed from the pubes. An incision 
is made through the skin in the median line above the pubes, two lines in 
length. A curved trocar (Fig. 1305) is then pushed through its w'alls in a 
direction backward and downward, while the organ is supported on either 
side by the hands of an assistant. The canula may be retained, or a gum 
catheter may be introduced through its canal before the former is removed, 
and can be kept in place by a strip of adhesive plaster or by tapes leading to 
the perineal strips of a T-bandage. A double canula, in which one tube slides 
within another, has been devised for the same purpose. This plan, from its 
simplicity, should, in all ordinary cases requiring tapping, be adopted. 
Tapping through the rectum.-Next in facility of execution is the operation 
through the rectum. The bladder is opened by this route in a triangular 
space at its base, which is devoid of peritoneal covering, and which is bounded 
in front by the prostate body and on each side by the vasa deferentia and the 
seminal vesicles. This operation is performed by means of a long curved 
trocar and canula. The rectum being emptied by an enema, the patient is 
placed on a table in the lithotomy position and with the hips projecting over PROSTATIC ENLARGEMENT. 
513 
its edge. The surgeon, oiling the index finger, introduces it into the rectum, 
and places its tip on the middle of the posterior border of the prostate body. 
Fig. 1305. 
Trocar for tapping the bladder. 
Taking now the trocar in the other hand, with its point drawn into the 
canula, the instrument is carried along the side of the finger as a guide until 
its extremity rests against the bladder, immediately behind the centre of the 
prostate body. The point of the trocar is now thrust out of the canula, when, 
by depressing the handle, the instrument is made to penetrate the recto- 
vesical walls and enter the bladder, which will be announced by the absence 
of resistance. 
As the trocar is withdrawn, the canula should at the same time be forced 
farther in, when, on separating the one from the other, the urine will escape 
with a gush through the tube. 
After the bladder has been emptied, the canula may be withdrawn ; or, if 
the urethral obstruction is of a character which renders successful catheter- 
ization improbable, it may be retained in situ by a T-bandage. 
Though the wound made in opening the bladder through the rectum usu- 
ally heals kindly, the procedure is not wholly without danger. It has been 
followed by abscess, urinary infiltration, fecal extravasation, and other evil 
consequences, some of which may not unjustly, I think, be referred to the 
unskillful manner in which the puncture was made. 
Tapping the bladder through the perineum, if executed with care, is also a 
simple operation, and attended with little danger. The plan is a very ancient 
one, and is described by Richard Wiseman as Molins's operation. It has, how- 
ever, been improved as well as simplified by Mr. Cock, a surgeon of London. 
The instruments required are a long, narrow, sharp-pointed, double-edged 
bistoury, a large probe-pointed director, and a catheter. 
The rectum being cleared of all feculent accumulations, the patient, having 
been first etherized, is placed in the lithotomy position, with the body and 
pelvis exactly in line. The surgeon, oiling the finger of his left hand, passes 
it into the rectum and plants it accurately against the apex of the prostate 
body. The knife is now entered at the median line or raphe of the perineum, 
and carried, without indecision, steadily onward until its point is felt at the 
tip of the finger which is in the bowel. 
By carrying the handle of the bistoury forward and backward the external 
wound may be enlarged, reaching in the posterior direction within half an 
inch of the anus. If the operator is assured that the tip of the finger rests 
against the anterior surface of the prostate, and that the point of the knife 
is similarly placed, he has only to give it a slight inclination to one side or 
vol. ii.-33 514 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
the other, and carry it boldly onward, in order to enter the urethra at the 
juncture between the membranous part of the canal and the prostate 
gland. 
Withdrawing the knife, but retaining the finger in its position, the operator 
next introduces the director through the incision, and, guided by the finger 
into the urethra, passes it on into the bladder. The catheter can now be in- 
troduced along the groove of the director, and after the removal of the latter 
may be retained in the bladder by means of a T-bandage. 
After thirty-six hours the instrument should be withdrawn, and an effort 
made again to introduce the catheter by the natural passage, when, if suc- 
cessful, the perineal opening may be allowed to close. If, on the other hand, 
the stricture continues to remain impassable, it will be better to convert the 
extemporized opening into a perineal section, executed according to the rules 
presented under that head, and in this manner remove the urethral obstruc- 
tion. 
Infra-pubic puncture of the bladder has been practiced by M. Voillemier: a 
trocar and canula were pushed underneath the arch of the pubes, alongside 
of the suspensory ligament of the penis, while the latter organ wras drawn 
strongly towards the perineum, the point of the instrument being directed 
downward and backward after passing the pelvic arch, in order that it might 
entei' the bladder a little behind the junction of its body and neck, and in 
that space where it is not invested by peritoneum. Though the wound rap- 
idly healed and the operation was entirely successful, no inference can be 
drawn from a single case as to its relative value. 
Interpubicpuncture, "which was 
originally suggested by a phy- 
sician of New Jersey, Dr. Bran- 
der, is performed by a trocar 
and canula, the instrument be- 
ing thrust through the sym- 
physis pubis, in a direction 
backward and downward, while 
the patient is in the recumbent 
position, and carried onward 
until the bladdei' is penetrated. 
After this is accomplished, the 
trocar is removed, and the can- 
ula, before being withdrawn, 
is employed as a guide through 
which to pass a gum catheter. 
There are a few cases of ves- 
ical tapping by this method, but 
it is exceedingly improbable that either the subpubic or the interpubic 
operation will meet with any marked favor when the aspirating trocar of 
Dieulafoy can be used with such great safety and ease. 
Fig. 1306. 
Tapping the bladder above the pubes, through the symphysis, 
and through the rectum. 
Diseases and Injuries of the Scrotum. 
Wounds of the Scrotum may be incised, contused, lacerated, or gunshot. 
Incised wounds are rarely seen except when made by the knife of the 
surgeon or in attempts at self-castration. 
Contused and lacerated wounds are frequently witnessed among mechanics, 
builders, and railroad-men, in consequence of the casualties to which they 
are exposed by falling timbers and by being caught between cars. 
Gunshot wounds of the scrotum are often complicated with similar injuries 
of the urethra, in consequence of which extensive sloughing is likely to follow 
from the extravasation of urine. 
Incised and lacerated wounds, after the ligation of any bleeding vessels, 
require to be-brought together by the interrupted suture. They heal generally DISEASES AND INJURIES OF THE SCROTUM. 
515 
with great rapidity, in consequence of the contraction of the dartos structure, 
which favors accurate apposition and leaves no vacuities in which serum or 
blood can collect. After the stitches have been introduced, the wound should 
be covered with a water-dressing or with carbolated oil, and the scrotum 
properly supported. In thirty-six or forty-eight hours the sutures can be 
removed. 
When the testicle is forced through a small rent or wound in the scrotum, 
as has occurred, unless immediate relief is at hand the contraction of the 
dartos may produce such a degree of strangulation of the gland as to require 
that the wound shall be dilated or enlarged by incision before the testis can 
be reduced. 
The same difficulty is said by Gosselin to follow even large wounds of the 
scrotum, if allowed to remain unclosed for some time, by the swelling of the 
testicle and its adhesion to the wounded integument. 
I have never witnessed anything of this kind. 
Contusions of the scrotum are followed by a diffused purple discoloration, 
from the extravasation of venous blood through the loose connective and 
dartos tissue which underlies the skin. 
Cold lotions of lead-water or of ice-water, and elevation of the part, will ful- 
fill every indication. 
Sometimes after a severe blow or kick on the scrotum a very large amount 
of blood may escape, forming a uniform enlargement or swelling, which might 
be mistaken for a similar collection in the tunica vaginalis. There is, how- 
ever, in the first no fluctuation at any time. The swelling is firmer, even 
doughy, in consistence, and the parts are discolored,-signs which do not be- 
long to uncomplicated hsematocele of the tunica vaginalis. 
It is possible, however, for both to exist at the same time, the latter being 
produced by the same violence that causes the scrotal extravasation. 
The treatment does not differ from that proper to simple contusion. In 
time the effusion, even though it be considerable, will be gradually removed 
by the veins and absorbents, leaving the parts unharmed. 
If, in consequence of the contusion and extravasation, the vessels are so 
compressed as to embarrass the circulation in the scrotum, abscess or even 
sloughing may follow. Should such a termination be threatened, the parts 
must be surrounded with wTarm-water fomentations, or, what is better, with 
warm flaxseed-meal poultices, giving exit to any purulent collections which 
may form, and favoring the separation of sloughs. 
Gunshot wounds of the scrotum, as in other parts of the body, heal by open 
granulations, and require nothing more than plain water-dressings. They are 
often tardy in cicatrization, in consequence of the disturbance to which they 
are subjected by the frequently recurring contractions and relaxations of 
the dartos muscle, which occur in consequence of the sloughing incident to 
such wounds. 
Should the scrotal or perineal urethra suffer in common with the scrotum, 
urinary extravasation into the latter may be anticipated: to prevent this 
the urine should be drawn with the catheter, or, if this has been neglected 
until the extravasation has occurred, it will be necessary to lay the scrotum 
open by a free incision, in order to draw away the urine and prevent sloughing. 
Prurigo and eczema of the scrotum are quite common affections. They are 
met with at all ages and at all seasons, though more common during the 
summer than during the winter months. These diseases are not limited to 
the scrotum, but extend to the inside of the thighs, to the perineum, and 
occasionally to the hypogastric region. The causes which give rise to these 
skin affections are, in children, phimosis, stone in the bladder, and contact 
with the urine, as in incontinence, atony of the bladder, etc. 
In old men the cause is to be sought for in some derangement of the 
digestive organs; and in this class of persons the disease often proves most 
intractable. 
The condition wffien due to prurigo is characterized by severe itching (which, 516 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
from its constancy, is peculiarly distressing) and by slightly-raised papules of 
a red color. 
In eczema the eruption primarily begins by the formation of minute vesi- 
cles. In consequence, however, of the scratching, which is irresistible in both 
affections, the parts become excoriated, cracked, and covered with a thin 
discharge, which hardens into crusts. The skin becomes hypertrophied from 
the transudation which takes place into the papillary layer of the derma, and 
an unpleasant odor is emitted, partly from the discharge and partly from the 
perverted secretion of the sebaceous glands of the scrotal integument. With 
some persons the severe itching is paroxysmal or intermittent, appearing 
after they have become heated with exercise or warm in bed, not much 
inconvenience being experienced during the day or while the patient is at 
rest. 
Treatment.-As a preliminary measure in the treatment, the cause must 
be carefully sought for. When associated with phimosis or with collections 
of smegma beneath the prepuce, the operation of circumcision or incision, and 
careful ablutions, will be demanded. 
In elderly persons suffering from the disease the digestive apparatus will 
require attention. A few grains of blue mass followed by a gentle cathartic, 
a carefully-regulated and unstimulating diet, together with tonics, as quinine 
or iron, or the infusion of gentian, with the bicarbonate of soda, or the use 
of nitro-muriatic acid, form the course of treatment best adapted to correct 
the constitutional disorder. The local management of these diseases is also 
very important. The parts require to be carefully cleansed, for which pur- 
pose daily ablutions with hot water and carbolic acid soap or bran-water 
answer the best purpose. These must be followed by the application of a 
stiff oxide of zinc ointment. Frequently the value of this ointment is en- 
hanced by incorporating with it a little tar ointment. In other instances, 
after bathing the scrotum with an alkaline wash, as a solution of the bicar- 
bonate of soda or of borax, and drying the skin, calomel should be thickly 
dusted over the surface. 
Citrine ointment, somew'hat weaker than the officinal strength, has been 
followed by excellent results when smeared over the affected parts. 
The severe itching is best relieved by a wash of carbolic acid and water 
(one drachm of the acid to six ounces of water), or by a solution of the 
bichloride of mercury (two grains and a half of the salt to three ounces 
of water), or by brushing over the scrotum liquor potassae diluted with one- 
fourth water. Fumigation of the scrotum with sulphur or cinnabar has also 
been used with good effect for the same object. Patients who suffer from 
these affections will find it conduce to their comfort to lie on a hard bed, 
with light covering, and to refrain as much as possible from scratching the 
affected parts. 
Parasites.-The pediculi pubis frequently find a habitat in the hair of 
the mons veneris and the scrotum. They are easily detected by the eye. 
Their eggs are deposited on the shafts of the hair, and can be recognized as 
small, knot-like bodies. 
The remedy for these disgusting lice is mercurial ointment rubbed over 
the affected region; or a solution of the hyposulphite of soda (5iss of the 
soda to water gij) may be applied freely as a lotion. Corrosive sublimate 
(two grains to the ounce of water) will also destroy these parasites in their 
ova. 
Varicose Veins.-The admirable support which is furnished by the dartos 
to the veins of the scrotum is unfavorable to the existence of varix; but 
where the tissues of the scrotum have become much relaxed, as in aged per- 
sons, or where they have been greatly stretched by large hernia?, or in bad 
cases of varicocele, I have several times witnessed well-marked cases of scrotal 
varix. The enlargement and tortuous disposition of these vessels are rarely (EDEMA OF THE SCROTUM. 
517 
confined to one side, but extend to both (Fig- 1307), and in some instances 
a similar condition of the dorsal veins of the 
penis is witnessed. 
The treatment is palliative, and consists 
in cold bathing and the use of a suspensory 
bandage. 
Fig. 1307. 
Pneumatocele, or Emphysema.-Air diffused 
through the connective and dartos tissues is 
always present in gangrene of the scrotum. 
It is sometimes produced artificially, as one 
of the tricks of mendicants and hospital 
malingerers. The distention is readily pro- 
duced, and without pain, by making a small 
puncture through the skin of the scrotum, 
inserting a small tube into the opening, and 
blowing air into the underlying loose con- 
nective tissue. The crackling on pressure and the resonance on percussion 
are sufficiently diagnostic of the condition. 
The air is gradually absorbed, or can be expelled by an incision through 
the integument of the scrotum, followed by the application of a narrow 
bandage from above downward. 
Varix of the scrotum. 
(Edema of the Scrotum occurs both as a primary affection and secondary to 
disease in other organs which may interfere with the circulation. 
As a primary condition it is seen in erysipelatous or other inflammation of 
the part, after the sting of a bee, in new-born children from local irritation, 
and occasionally in aged, debilitated persons. 
The diseases which are influential in causing scrotal oedema are cardiac 
and renal dropsy, epididymitis, pelvic tumors, and inguinal tumors. I have 
seen it follow the use of the exploring needle in cases of hydrocele. 
Symptoms.-(Edema usually appears as a uniform, globular swelling, in- 
cluding the entire scrotum, and doughy or inelastic in its consistence. Press- 
ure causes a slight depression, which remains for a very short time after 
the removal of the finger. 
The swelling commences in the most dependent part of the scrotum, and 
as the serum accumulates in the subcutaneous connective tissue, it gradually 
rises, obliterating, as it does so, the normal rugte of the integument, until 
the skin becomes pale, smooth, glossy, and translucent. 
As the accumulation increases, the serum extends to the cellular tissue of 
the penis, the skin of which assumes very much the same appearance as 
that of the scrotum, the prepuce also becoming singularly twisted. 
The diagnosis of oedema is not a matter of difficulty. The doughy, inelastic 
feel, the slight pitting on pressure, the semi-transparency of the skin, the 
obliteration of the natural rugae, the shining, glossy appearance of the integ- 
ument, and the bilateral nature of the swelling are sufficient to distinguish 
the affection from hydrocele, the only disease with which it is likely to be 
confounded. 
In rare instances the oedema has been limited to one side, a fact which led 
Pott, on one occasion, to puncture the swelling with a trocar, under the im- 
pression that he was dealing with a hydrocele. 
Treatment.-It is only when the distention of the skin is so great as to 
threaten its vitality that it is necessary to address any specific treatment to 
the parts, when it will be proper to make, with a large needle, two or three 
punctures through which the serum may drain away. Incisions should be 
avoided, as they are liable to be followed by sloughing. If the remedies 
which are addressed to the removal of the diseases on the existence of which 
scrotal oedema depends, prove efficient, the latter may be expected to disap- 
pear. 518 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Inflammation of the Scrotum is not very frequently seen outside of hos- 
pital practice. It is rarely traumatic in its origin, nor do persons of strong, 
vigorous constitutions often suffer from an attack of this nature. Adults 
and aged individuals, especially those of intemperate habits, or who have 
been subjected to severe deprivation, exhausting employments, or bad usage, 
are the subjects most commonly attacked. The inflammation is erysipelatous 
in its character, and may be developed by the irritation consequent on the 
dribbling of urine, or from a pimple which has become inflamed by scratch- 
ing. The skin of the scrotum grows dusky red, swollen, and cedematous. 
The corrugations of the integument disappear, and the parts assume a 
smooth, shining appearance. The swelling is not limited to the scrotum 
alone, but extends to the penis, insides of the thighs, and inguinal regions, 
and is accompanied with thirst, rigors, a hot, dry skin, coated tongue, and 
other signs of febrility. In consequence of the great abundance of loose 
connective and muscular tissue underlying the skin of the scrotum and the 
dependent position of the latter, the swelling and oedema are necessarily very 
marked, as both are favorable to a free and sudden transudation of serum. 
It was from these peculiarities, no doubt, that Mr. Liston,* who has recorded 
a number of such cases, adopted for the disease the name " acute anasarca of 
the scrotum." 
In favorable cases these symptoms gradually subside by resolution, or ter- 
minate in suppuration, without causing any serious structural damage to 
the scrotum. But in the graver variety of the affection the infiltration is 
so rapid and so large, and subjects the vessels to such severe pressure, that 
the subcutaneous tissues are extensively destroyed by mortification, without 
much suppuration, leaving, after the separation of the sloughs, the testicles 
entirely uncovered and a portion of them gangrenous. Twice have I seen 
almost the entire scrotum destroyed. The devastation is accompanied by a 
feeble pulse, a dry, dark tongue, great exhaustion, retention of urine, and the 
other symptoms of a typhoid state of the general system. 
Diagnosis.-The only affections with which this inflammatory condition 
of the scrotum can be confounded are urinary extravasation and oedema. 
From the first the distinction may be established by a previous history of 
stricture or of injury to the perineum, the difficulty that will be experienced 
in introducing a catheter into the bladder, and the precedent swelling in the 
perineum, all of which distinguish urinary infiltration from rupture of the 
urethra. 
In simple oedema of the scrotum there is little tenderness and no constitu- 
tional disturbance. 
Prognosis.-Though the disease occasionally proves fatal in defiance of 
the most judicious treatment, yet, generally, patients recover after a some- 
what tedious convalescence. 
Treatment.-The scrotum should first be elevated by placing underneath 
it a soft cushion, and should then be covered with a warm lotion of lead-water 
and laudanum. If the bowels are not freely open, a gentle cathartic, preceded 
by a few grains of blue mass, will be indicated; while, with a view of allaying 
febrile excitement, the neutral mixture may be administered every two or 
three hours. Should the disease tend to a favorable termination under this 
plan, it will have reached its culmination in the course of three or four days, 
from which time the swelling, oedema, and other symptoms will undergo a 
steady declination, until, in the course of ten or twelve days, all traces of the 
disease (except, perhaps, some slight oedema and thickening of the integu- 
ment, with desquamation) have disappeared. 
When, however, there is great tension of the integument, with the signs of 
suppuration, or if in connection with this tension the skin becomes dark and 
discolored, threatening mortification, there will be an urgent necessity for 
making two or three incisions at the most dependent portion of the scrotum, 
extending through the integument and the subcutaneous tissue, in order to 
* Medico-Chirurgical Transactions, vol. xxii. TUMORS OF THE SCROTUM. 
519 
unload the latter of the inflammatory products, and thus prevent, or at least 
limit, the sloughing, after which the warm-water dressings or poultices 
should be applied. When sloughing does occur, laying bare the testicles, the 
best local application will be a flaxseed-meal poultice, having a little yeast 
spread over its surface, to correct the odor emanating from the dead tissue, 
always observing to wash the parts well with a solution of permanganate 
of potash and to pick away any loose sloughs before applying the poultices. 
As soon as all the dead tissue has been detached and granulation has com- 
menced, a dressing of sweet oil and carbolic acid may be substituted for the 
poultices until cicatrization has been completed. 
Nor must the general treatment be overlooked. There will be an impera- 
tive necessity for the administration of tonics and stimulants, as quinine and 
iron, wine-whey, milk-punch, milk, beef-tea, eggs, and such other articles of 
nourishment as the patient may be able to take. 
Mortification of the Scrotum is occasionally witnessed independent of an 
inflammatory cause. It may result from a severe scald, from embolism of 
the supplying vessels, or from frost-bite. Curling has seen one instance of 
the latter, and Sir Astley Cooper mentions a second, in the person of a sol- 
dier who was much exposed to intense cold during the retreat of the army 
in the Netherlands, under the Duke of York. Professor Gross has seen a 
case of idiopathic sloughing in an infant two weeks old, which destroyed a 
circumscribed portion of the scrotum down to the tunica vaginalis. 
From whatever cause the mortification arises, the system will demand a 
generous support by tonics, stimulants, and food; and, with a view to effect 
a rapid separation of the dead tissue, warm poultices, spread with the com- 
pound resin ointment, must be applied, and the parts should be thoroughly 
cleansed and deodorized, at each renewal of the dressing, with lotions of per- 
manganate of potash or carbolized water, until granulation begins, when the 
carbolated oil dressing will answer every purpose. 
Even when the testicles and cords have been completely denuded I have 
seen the destruction entirely repaired by the reproduction, through granula- 
tion and cicatrization, of a new scrotum, somewhat different from the original 
(especially in the absence of the dartos muscle), but still sufficient for the 
purpose of protection. 
Redundancy of the Scrotum is usually the effect of extreme stretching from 
a large varicocele or hernia. It will rarely demand operative interference, 
cold ablutions, with a suspensory bandage, being quite sufficient to make the 
patient comfortable. Should anything more radical be required, the object 
can be obtained by raising transversely a sufficient duplicature of the scrotal 
integument and cutting it away with the knife, when the edges of the wound, 
after all the vessels have been secured, must be brought together by several 
interrupted sutures, and the part covered with a water-dressing and kept well 
supported until union has taken place. 
The tumors which are met with in the scrotum are cystic, fatty, fibrous, 
carcinomatous, enchondromatous, and that hypertrophy known as elephantiasis. 
Tumors of the Scrotum. 
Cystic Tumors are of two kinds, the one consisting of a dilated sebaceous 
follicle and containing a cheesy-looking matter, and the other a wall of 
densely compacted connective tissue surrounding an oval or irregular-shaped 
cavity containing a transparent serous or a yellow viscid fluid. (Fig. 1308.) 
These tumors may possibly have a common origin in the sebaceous follicle, 
but their infrequency and the limited number of observations which have 
been made leave some uncertainty as to the manner of their formation. 
These tumors are commonly multiple, several existing in the scrotum at 
the same time. They vary in size from a grain of shot to a hen's egg. 520 
INJURIES AND DISEASES OF THE GEN1TO-URINARY ORGANS. 
Cases of this disease have been observed by Mr. Crompton,* of Birming- 
ham, England, by Barechet,f and by Fleming. 
When these tumors continue to 
grow, they should be removed. The 
operations of this kind which have 
been performed appear to have been 
successful, as no mention is made of 
the recurrence of the disease. 
Fig. 1308. 
Adipose Tumors of the Scrotum are 
rare. They are developed in the 
subcutaneous connective tissue, and 
consist of an aggregation of lobules 
of fat. They have a doughy feel, 
communicate a deceptive sense of 
fluctuation to the fingers on palpa- 
tion, and, when the lobulated contour 
of the tumor cannot be distinguished, are not easily recognized. 
The disease may be associated with a large deposition of fat over the ab- 
domen, continuous with the scrotal mass, as in Gray's case, described by Mr. 
Curling, and also beneath the integument of the penis, as in the case de- 
scribed by Mr. Hogg and Sir Henry Thompson, recorded by the same writer. 
The remedy is excision. Operations have been done by Dr. Kimball, of 
Lowell, Massachusetts, by Mr. Lane, of St. Mary's Hospital, and by Mr. Birkett. 
Section of cystic scrotal tumor.-From Curling. 
Fibrous Tumors are rarely seen in the scrotum. When present, they occur 
as a single, dense mass of connective tissue, having a uniform, smooth sur- 
face, or in a number of small lobules connected together. They occasion- 
ally grow to a large size. In one of Mr. Paget's cases, the tumor weighed 
twenty-four pounds; in another, mentioned by Mr. Curling, the weight was 
twenty-three pounds; and in a third, recorded by Lesauvages, the tumor 
weighed forty-four pounds. 
These growths are subject to singular transformations or degenerations. 
In an immense tumor of this kind, removed by Dr. Mott, a large amount of 
calcareous matter was found imbedded. 
Fibromatous growths of the scrotum are distinguishable from all other 
affections in this region by their density, and by the healthy condition and 
absence of transparency of the superincumbent skin. 
Treatment.-The proper remedy for fibrous growths of the scrotum when 
the disease is progressive is excision. The operation is generally followed 
by a permanent cure; though in a case operated on by Sir William Fergussonj; 
the disease returned. 
In almost all recorded cases of scrotal fibroma the patients were well ad- 
vanced in life. In only one case, that of Mr. Lane, mentioned by Curling, 
was the patient very young, namely, two years and a half. 
Enchondroma is the rarest of all tumors of the scrotum. One case is re- 
corded by Dr. Kerr,§ an American surgeon in Canton, China, which occurred 
in a native, and which was excised. The growth was as large as a child's 
head, and when examined was found to consist of cartilage and true bone 
curiously intermingled. 
Scrotal Calculi.-Concretions of this nature occasionally form in the scrotum, 
in consequence of a fistulous opening existing between the latter and the 
urethra or the bladder. The records of surgeons contain some singular in- 
* Curling on the Testes, p. 624. 
f Archives Generates de M6decine, vol. ii. p. 70, 1858. 
j Medical Times and Gazette, vol. xiv. p. 166. 
$ North American Medico-Chirurgical Review, January, 1858. ELEPHANTIASIS SCROTI. 
521 
stances of such formations. Mr. Holmes mentions a stone, which is in the 
Norwich collection, weighing eight ounces, which is represented as having 
been removed from the scrotum. 
Von Graefe also speaks of a case in which a similar concretion, weighing 
twenty-six ounces, was discharged from the scrotum of a shoemaker, the tis- 
sues having given way in consequence of the weight of the concretion. These 
calculi are similar in composition to those which form in the pouches of a 
sacculated bladder, being made up for the most part of uric acid or of phos- 
phate of lime. 
Elephantiasis Scroti, though rarely seen in the temperate latitudes of 
North America and Europe, is very common in India, Africa, Asia, Syria, 
Egypt, Arabia, China, the East and West Indies, and South America. The 
disease is of the same nature as the Barbadoes leg; and the same maybe 
said of the hypertrophied labium of the female, which is frequently seen in 
hot climates. 
Heat and moisture exert a strongly determining influence on the produc- 
Fig. 1309. 
Fig. 1310. 
Professor Neill's case of elephantiasis of scrotum and penis. 
tion of the disease, even in those countries where elephantiasis prevails. 
In India the large proportion of cases occur along the sea-coast and in the 
Neill's case after operation. 522 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
neighborhood of Bengal. In Egypt the disease is limited to the Delta of the 
Nile. 
The growth consists in a hypertrophy of the tissues of the scrotum, the 
penis participating in the disease. The surface of the skin becomes thickened 
and indurated, sometimes rugose, knotty, crossed with deep fissures, and 
covered with crusts. 
The most striking change, however, is in the enormous hyperplasia and 
hypertrophy of the subcutaneous connective tissue, which is white, dense, 
and callous, cutting almost like cartilage, its lymphatics filled with a gelati- 
nous fluid, rich in albumen, its veins enlarged and tortuous, remaining patu- 
lous when divided, and surrounded with colossal lymph-cells. In the poste- 
rior part of this hypertrophy the testicles lie imbedded, and in its anterior 
part the penis, when the latter is involved in the disease. 
Masses of fat and earthy concretions are occasionally found scattered 
through the dense, fibrous mass, and in some instances erectile growths have 
been observed by Fayrer. 
The testes generally remain sound. In consequence of the great weight 
of the tumor, the spermatic cords are necessarily very much elongated, and 
the cremaster is much thickened. In the cavity of the tunica vaginalis there 
is more than the normal quantity of fluid, frequently amounting to hydro- 
cele. The shape of the tumor is usually pyriform or ovoidal (Fig. 1309), 
Sub-Fig. 1. FlG. 1311. SuB-FiG. 2. 
Skin of scrotum in elephantiasis Arabum, 225 diameters. Sub-Fig. 1 exhibits a section of the deep 
layer of the corium : a, a, a, a, bands of fibrous tissue, with numerous free nuclei, granular matter, 
and connective-tissue corpuscles interspersed through its meshes; also, cells with two nuclei; b, walls 
of artery infiltrated with cells ; c, cell mass and adipose tissue atrophied. Sub-Fig 2, vertical section of 
epidermal and capillary layer: a, b, horny layer of epidermis, in a measure detached; c, rete mucosum; 
d, cylindrical cells which contain much pigment; e, papillary layer, with cell infiltration and the 
remains of capillaries, and entire absence of hair follicles and of sudoriparous and sebaceous glands. 
Below the papillary layer are enlarged lymph spaces, f, g, h; k, blood-vessels, their walls thickened 
and fibrous. 
having a broad, pedunculated attachment to the body, the skin being drawn ELEPHANTIASIS SCROTI. 
523 
from the hypogastrium and the perineum. Under the crusts which cover 
the surface of the growths are superficial ulcerations, which furnish a sanious 
discharge having an offensive odor. Very little inconvenience is experienced, 
except from the magnitude and weight of the scrotum, and from this cause 
the latter sometimes mortifies, leaving the testicles uncovered. Dr. Hendy 
mentions six cases which terminated in this manner. 
Elephantiasis is a chronic inflammatory disease produced most probably 
by miasmatic influences, and affecting chiefly the lymph-vessels. The obser- 
vations made by Lewis and by Manson on the presence in the blood of persons 
suffering from this affection, of filariae, which are thought to give origin to 
the disease, are quite worthy of perusal. 
The microscopic appearances of the skin of the scrotum in the tumor re- 
moved by Dr. Neill are very well exhibited in the drawing prepared by Dr. 
Shakespeare (Fig. 1311), from which Sub-Figs. 1 and 2 have been taken. 
Elephantiasis of the scrotum sometimes attains enormous dimensions. 
Titley's case, which is represented in 
the accompanying cut (Fig. 1312), 
weighed seventy pounds. Liston re- 
moved a growth of this kind weighing 
forty-five pounds. The remarkable 
case of Delpech, preserved at the old 
school of Montpellier, in the south of 
France, is said to have weighed sixty 
French pounds, or one hundred and 
sixty pounds avoirdupois. Baron Lar- 
rey speaks of one which weighed one 
hundred and twenty pounds; and 
several others might be mentioned in 
which the weight varied from fifty to 
one hundred and twenty pounds. 
Treatment.-Very little can be ac- 
complished by internal treatment. Io- 
dide of potassium, iodine, arsenic, iron, 
quinine, and other remedies have been 
administered. As alteratives and tonics 
they are not entirely devoid of value. 
A removal from the district where the 
disease has been contracted to another 
climate is deemed by Fayrer to be the 
most efficient means of arresting the 
growth. 
When the bulk of the tumor becomes 
so great as seriously to interfere with 
the comfort of the patient, the knife 
is the proper remedy. The operation is among the most formidable in sur- 
gery. Many patients have perished on the table, or a very short time after 
the excision has been completed. 
A Chinaman, from whom Ashton Key removed a growth of this kind 
weighing upwards of fifty-six pounds, died immediately after the operation 
was over. The same result followed a case of excision in the hands of Mr. 
Liston. Mr. Wilks lost a case, the patient dying before the excision was fin- 
ished, having been on the table nearly eight hours. This tumor measured 
nearly six feet in circumference, and was two feet five inches in length. 
Dr. Esdaile, of Calcutta, has operated 161 times, with a mortality of only 
5 per cent.; Dr. Ballinghall, of Bombay, 21 times, with 2 deaths; and Fay- 
rer 28 times, with 6 deaths. The mortality following 113 operations done 
at the hospital of the medical college at Calcutta, during a period of eight 
years, was 18.58 per cent. 
In this country the operation has been performed a number of times, the 
Fig. 1312. 
Titley's case of elephantiasis scroti. 524 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS 
operators being Bozeman, whose patient died two weeks after the excision, 
Picton, of New Orleans, Thebaud, of New York, and Neill, of Philadelphia, 
all of whose cases recovered. 
Formerly, when the tumor was very large, in order to save blood and 
shorten the operation it was advised to sacrifice the testicles; but, with our 
present improved means of controlling hemorrhage, this can rarely be 
required. 
Before beginning the operation the tumor should be elevated, in order to 
drain the vessels of their blood, during which time the anaesthetic can be 
administered. To render the operation as bloodless as possible, an Esmarch 
bandage should be applied to the mass from below upward. The tubing 
being next secured round the pedunculated base of the growth, close up to 
the pubes, the elastic roller can be removed, when the surgeon proceeds to 
dissect out the penis from the anterior and middle part of the mass, and the 
testicles from either side. A sound or catheter previously introduced into the 
urethra will serve to establish the locality of the penis. Any vessels which 
spring should be ligated or secured by forceps as the operation proceeds. 
In the case operated on at the University Hospital by Professor Neill, I 
tied probably not less than sixty or seventy vessels. 
As soon as the testicles and penis have been isolated, the surrounding 
fibrous mass must be cut away, leaving only a sufficient amount to form 
three flaps, one anteriorly for the penis and one on each side for the testicles. 
As these cases of elephantiasis are occasionally complicated with rupture, 
the surgeon must keep before his mind the possibility of encountering a 
hernial sac, which, if present, will require to be carefully detached from the 
tissues around. Dr. Ballinghall, in one instance, inadvertently cut into the 
sac of a hernia while excising an elephantiasis of the scrotum. After the 
tumor has been removed, the edges of the wound are to be drawn together 
by interrupted sutures, a dressing applied, and an opiate administered. The 
subsequent treatment will consist in sustaining the patient until the cure has 
been effected. 
Lymph Scrotum.-A form of modified elephantiasis described by Dr. Car- 
ter in 1861, and which has been studied by Dr. Manson and by Dr. Macleod, 
consists in an inguinal adenitis, preceded by fever of a miasmatic origin, and 
followed by an inflammatory enlargement of the scrotum and the testes. 
The inflammation of the scrotum ordinarily ends in suppuration, leaving 
the integument rough and indurated, with numerous vesicles scattered over 
its surface. When these vesicles open, a straw-colored fluid is discharged 
having all the characteristics of chyle, and containing filariae similar to those 
found in the blood of persons laboring under elephantiasis. 
The inguinal glands along the line of Poupart's ligament and over the 
saphenous opening are greatly enlarged. (Fig. 1313.) The hypertrophy of 
the scrotum in this affection, however, is not so much due to hyperplasia 
of its connective tissue as to the dilatation of the lymph-vessels and the 
accumulation of lymph in the papillary and deeper layers of the skin. This 
is shown by what follows the puncturing of the vesicles, the swelling rapidly 
subsiding and shriveling as the fluid drains away. 
The disease is met with in China and in India, and is believed to be due 
to malarial agency. The obstruction to the lymph-vessels is supposed to be 
the result of a precedent inflammation of the inguinal glands, the infiltration 
of which, by compressing the afferent lymphatics coming from the generative 
organs as they enter these bodies, prevents the entrance of the lymph, in 
consequence of which it is dammed back. This explanation, however, is 
scarcely sufficient to account for the enlargement alone, as we constantly 
observe inflammatory enlargements of the inguinal glands without any similar 
phenomena. 
Rindfleisch,* in speaking of these hypertrophies of the scrotum and penis 
« Pathological Histology, p. 313. EPITHELIOMA OF THE SCROTUM. 
525 
and mons veneris, and which he terms pachydermia lymphangiectatica, attaches 
much importance to the role played in cases of elephantiasis by the organic 
muscular fibres of the corium, which 
he alleges are the subject of a spe- 
cial hyperplasia and neoplasia, and 
which, by their contraction, so con- 
strict those perpendiculai* vessels 
which establish a communication 
between the superficial and deep 
net-work of lymphatics, as to cause 
a stagnation in the former, and thus 
produce the characteristic swelling 
and lymph vesication. On this 
theory, the lymph swelling of the 
scrotum would be simply lymphatic 
congestion of and transudation 
through the subcutaneous lymph- 
vessels. But we cannot stop here, 
as in some instances at least there 
also exists a hypertrophy of the con- 
nective tissue, the reality of which 
has been shown by the excisions 
which have been practiced for the 
removal of scrotal tumors of this 
nature. 
The treatment for lymph scrotum 
is quinine, iodine, and change of climate. Where, along with the lymph 
swelling, there exists increasing hypertrophy of the connective tissue, excision 
will be required. 
Fig. 1313. 
Lymph scrotum.-From Carter. 
Epithelioma of the Scrotum, commonly known as the "chimney-sweep's 
cancer," or "soot cancer," has almost entirely disappeared since the intro- 
duction of coal for the purpose of heating dwellings. The disease generally 
begins as a wart-like body, situated at the most dependent part of the scrotum. 
In most instances a single wart is present, though sometimes there may be 
several. These excrescences, after a time, soften, their surfaces becoming 
inflamed, abraded, and covered with incrustations which are detached 
later; the callous surface of the wart finally softens, ulcerates, and ter- 
minates in an open sore, superficial in depth, with hard, irregular, everted, 
sometimes inverted, and undermined edges, and furnishing a thin, ichorous 
discharge. (Fig- 1314.) As the disease advances, the ulcer enlarges in both 
circumference and depth, until the entire scrotum and 
the tunica vaginalis are destroyed. The disease seems 
to have little tendency to attack the testicle. Its ravages 
are not confined to the scrotum alone, but may extend to 
the perineum, the penis, and the mons veneris. 
The inguinal glands do not participate in the disease at 
an early period, but finally become enlarged, indurated, 
and painful. They suppurate, open, and discharge an 
offensive blood-stained fluid, having, like that from the 
sores of the scrotum, an offensive odor, and leaving 
deep ulcers, which continue to enlarge in every direc- 
tion. The general system in time sympathizes with the 
local disorder; the appetite fails, the patient loses flesh, 
passes sleepless nights, is harassed with darting pains, 
and begins to present that peculiar sallow or waxy color 
of the face which reveals the nature of the cachexia, 
until, finally, worn out by continued suffering, death comes to his relief. 
As has been stated, epithelioma of the scrotum is commonly a disease of 
Fig. 1314. 
Epithelial cancer of the 
scrotum. 526 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
chimney-sweeps, and is caused by the soot lodging in the depressions between 
the corrugations of the integument, where it slowly acts as an irritant. But 
there is doubtless more required for the production of the affection than 
occupation, as comparatively few chimney-sweeps are attacked, and in some 
the warts remain as harmless excrescences. There is probably, as in epi- 
thelial carcinoma elsewhere, some predisposing constitutional condition which 
underlies the local lesion, and on which depends its benign or malignant course. 
The operation of the irritant is exceedingly slow, as it is rarely, if ever, 
met with in boys, by whom this work is done; adults between thirty and 
forty being the persons who generally suffer. 
I have never seen a case of the disease in Philadelphia or elsewhere in this 
country. It is said to be unknown in France, and rarely witnessed in Ger- 
many. The comparative prevalence of the affection in Great Britain at one 
time was probably due to the quality of coal used as fuel. 
Soot, when applied to other parts of the body than the scrotum, is capable 
of producing a sore. Gardeners, who sometimes use this material for the 
destruction of insects which infest the leaves of certain plants, have suffered 
from irritable sores on the hands. Dr. Paris has seen cases of scrotal epithe- 
lioma occur in smelters. 
Epithelioma of the scrotum is generally very slow in its progress, seldom 
proving fatal sooner than from six to eight years, and in some instances after 
a much longer period. 
Treatment.-Early excision is the proper remedy, including in the opera- 
tion the sound tissue of the scrotum some distance beyond the visible limits of 
the disease. The vessels must be all carefully tied, and the wound closed with 
interrupted or twisted sutures. If the operation is undertaken early, there 
will be a reasonable probability that the disease will not return. When the 
glands of the groin are implicated in the disease, they should also be removed. 
When the disease is too far advanced for the knife, the only resource is 
to palliate, by the administration of opiates to relieve pain, by cleansing the 
parts frequently, and by the employment of mild unirritating dressings. 
Medullary and melanotic carcinoma rarely occur in the scrotum primarily. 
Two cases of the latter disease have been recorded by Curling, one seen by 
himself and the other recorded by Ronge, of Lausanne, Switzerland. 
Cystitis. 
Cystitis, in the general acceptation of the term, means inflammation of the 
mucous membrane of the bladder. The othei- tunics of the viscus are not 
exempt from inflammatory attacks; but when they suffer, it is not usually a 
primary condition, but an extension of the disease, either from the peritoneal 
or the mucous side of the organ. Thus, we have pericystitis, or inflammation 
of the cellular tissue connecting the peritoneum and the bladder; vesical 
peritonitis, or epicystis ; and interstitial cystitis. When cystitis occurs, all the 
coats of the organ are affected, both in the acute and in the chronic form. 
Acute cystitis is not a very common affection ; it may arise from traumatic 
causes, from an extension of inflammation from neighboring parts, and from 
the poisonous effects of certain drugs. 
Among those forms of the disease having a traumatic origin are such as 
arise from lithotomy, lithotrity, catheterism, and foreign bodies in the blad- 
der, as stone, or substances which enter the viscus designedly through the 
urethra or accidentally through the walls of the abdomen or the pelvis. 
Among the foreign substances the depositions from decomposed urine may 
also be included. When developed by an extension of disease from adjacent 
parts, it is in consequence of a pre existing gonorrhoea, a prostatitis, or an 
inflamed stricture. 
The drugs which have a tendency to affect injuriously the mucous mem- 
brane of the bladder are cantharides and oil of turpentine, which operate 
physiologically through the general system, and caustics, as nitrate of silver CYSTITIS. 
527 
and the mercurial acids, which are sometimes employed as injections, and 
which operate chemically. 
Cystitis is more common in men than in women. 
Symptoms.--The symptoms of cystitis in its commencement differ some- 
what according to the determining cause. When traumatic, it may be an- 
nounced by chills followed by febrile excitement. In other instances, and 
when from other causes, it is ushered in by a feeling of uneasiness, which is 
located deep in the perineum, about the neck of the bladder, accompanied 
by frequent calls to urinate, attended with pain and vesical tenesmus, and a 
scalding sensation experienced along the whole extent of the urethra. The 
bladder becomes exceedingly intolerant of the pressure of the urine, which is 
expelled in small quantities, but without affording any feeling of relief. Ten- 
derness and fullness are experienced in the bypogastrium and the perineum, 
and from these regions darting pains frequently extend along the urethra to 
the testicles, to the lumbar and sacral region, and down the inner sides of the 
thighs. The urine soon undergoes changes in quantity, appearance, and 
quality. It becomes scanty, alkaline, and at first high-colored, then reddish 
and cloudy, containing blood, and finally ropy, thick, turbid, muddy, puru- 
lent, containing much vesical epithelium, and heavily charged with urates 
and amorphous phosphates. 
The extreme irritability of the neck of the bladder is often such that, after 
a few drops of urine escape, it becomes spasmodically closed, so that the 
organ is not relieved of its contents, which gradually accumulate, until it 
forms a distinct tumor above the pubes. 
I he constitutional disturbance, when the disease is of a grave form, is very 
marked, as indicated by a frequent and resisting pulse, thirst, headache, and 
nausea, with great restlessness and mental anxiety. 
When the cystitis arises from an extension of gonorrhoeal inflammation, 
the disease is confined chiefly to the neck of the bladder, and the local 
symptoms of weight, fullness, tenesmus, and constant micturition are even 
more incessant and distressing than when the disease arises from traumatic 
causes; but, though there may be even greater mental disquietude, there is 
a singular freedom from signs of febrility. 
When cystitis progresses towards a fatal termination, portions of the walls 
of the bladder may suppurate or even slough, and be discharged in stringy 
fragments ; the urine emits a horrid odor, from the products of its own decom- 
position and the gases resulting from the dead mucous and submucous tissue 
which it contains; the patient is harassed with hiccough; the pulse becomes 
very frequent and small, the tongue dry and hard, streaked with a dark coat; 
the strength rapidly fails; the secretion of the kidneys diminishes or is en- 
tirely suspended; the countenance becomes sunken and cadaverous, the ex- 
tremities cold, the surface moistened with perspiration, from which emanates 
the odor of urine, and the patient at last passes into a state of profound 
stupor, from which he never awakes. 
The course of acute cystitis is ordinarily very rapid, rarely extending 
beyond eight or ten days, when, should it not terminate in resolution, the 
disease gradually passes into the chronic form. 
Acute cystitis at the neck of the bladder may be confounded with acute 
prostatitis; but there are certain marked differences between the two dis- 
eases which, when contrasted, will enable the practitionei* to reach a positive 
diagnosis.* 
CYSTITIS. 
Much pain experienced in passing the last 
drops of water in urination. 
Tenesmus constant and urgent. 
The discharge of a thick, turbid, ropy fluid at 
the termination of the micturition. 
Retention of urine not common. 
Prostate body normal. 
PROSTATITIS. 
Comparatively little pain. 
Neither constant nor severe. 
Urine little changed. 
Retention common. 
Enlarged, which can be ascertained by digital 
examination through the rectum. 
® For additional differential symptoms, see page 495. 528 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
Pathology.-The changes which are produced by acute cystitis consist in 
increased vascularity of the mucous membrane, its light-red color being ex- 
changed for one of a scarlet hue, more strongly marked at some portions of 
its surface than at others. In consequence of the over-strained vessels giving 
way at certain points, patches of ecchymosis may be also seen. The inflam- 
matory redness often exists in spots, imparting a mottled appearance to the 
mucous membrane. These circumscribed districts of color are found to con- 
sist of zones of vascularity around the glands which lie imbedded in the 
submucous connective tissue and which have participated in the general in- 
flammation. In addition to these structural alterations, the membrane is 
swollen, softened, and sometimes ulcerated at points. Nor are the inflamma- 
tory changes always limited to the mucous and submucous tunic and peri- 
mysium. They may involve all the coats, and even extend to the vesico- 
peritoneal cellular tissue, occasioning by the resulting interstitial infiltration 
marked thickening or suppuration in and about the walls of the bladder, 
together with peritonitis. As in the mucous membrane of the fauces and 
larynx and trachea in inflammatory diseases, so in that of the bladder there 
may be foreign deposits and fibrinous membranes, fragments or shreds of 
which are sometimes discovered in the urine. 
Treatment.-Acute cystitis demands prompt treatment. The patient 
must be placed in bed with the hips elevated; blood should be taken from the 
perineum by leeches; the bowels must be kept open, but not actively purged; 
hot hip-baths for twenty minutes are to be twice or thrice repeated during 
the twenty-four hours, followed by flaxseed-meal poultices to the perineum 
and over the hypogastric region as warm as can be borne. The patient must 
also be allowed the free use of alkaline diluent drinks, as flaxseed or slippery- 
elm tea containing a little bicarbonate or citrate of potash. 
The vesical irritability will be best allayed by suppositories of opium with 
the extract of hyoscyamus. The diet must consist for the first three or four 
days exclusively of milk. In the event of retention taking place and not 
being relieved by the hip-bath and an anodyne enema, it will be necessary 
to draw the urine with a soft catheter; but under no circumstances is the 
instrument to be allowed to remain, as it would add to the severity of the 
local inflammation. 
When the cystitis has been produced by the presence of a foreign body 
in the bladder, the treatment will not materially differ from that detailed. 
But no operation should be attempted for the removal of such body during 
the acute stage of the attack. 
When local congestion, or that irritation of the neck of the bladder called 
strangury, is developed by the specific action of cantharides (either from 
the absorption of cantharidin through a blistered surface or from the inter- 
nal employment of the drug) or by the action of a terebinthinate, the use 
of the drug must be suspended at once, an enema administered consisting 
of two tablespoonfuls of starch-water and forty drops of laudanum for an 
adult, and diluent drinks freely given. 
Chronic Cystitis, Vesical Catarrh, or Cystorrhoea.-This is the most common 
and the most intractable of all affections of the. bladder. It is invariably the 
result of some pre-existing disorder of the urinary passages, and in a large 
number of cases is beyond the reach of any remedial measures whatever. 
It is not peculiar to any time of life, though commonly met with in persons 
beyond the middle period, males being more frequently the subjects of the 
disease than females. 
Causes.-The causes of chronic cystitis arc such as interfere with the 
complete evacuation of the contents of the bladder, and are consequently 
obstructive, as the existence of sacculi, stricture, gleet, hypertrophy of the 
prostate, paralysis of the bladder, and morbid growths within the viscus. 
Among mechanical causes may be mentioned stone, the frequent use of in- 
struments, and the muscular weakness which results from over-distcntion of CHRONIC CYSTITIS. 
529 
the organ. Associated with this dilatation is a form of vascular paralysis 
resulting from the sudden removal of pressure, which leaves the vessels in 
a helpless and congested condition favorable to inflammatory accidents. 
The foundation for chronic cystitis is often laid by too long retention of 
the urine, and it may originate from the same cause in persons who, in con- 
sequence of extreme weakness of body and the mental hebetude which at- 
tends protracted attacks of illness, are not keenly conscious of the sensations 
of their internal organs,-a fact which suggests the necessity for the physi- 
cian's being always aware of the possibility of such complications and inter- 
fering for their prompt removal. Alterations in the urine which may occur 
even before it has reached the bladder, as when it results from disease of the 
kidneys, though among the less common causes of the disease, are influential 
in producing chronic inflammation. 
Symptoms.-Chronic inflammation exists in different degrees of severity. 
It may be characterized only by a frequent desire to micturate and a cloudy 
appearance of the urine, due to the presence of mucus and a small amount 
of pus. 
In the more pronounced form of the disease the calls to urinate become 
more frequent, only a small quantity of water being passed at each act. 
Considerable smarting and pain are felt along the course of the urethra, and 
an unsatisfied feeling, as though the bladder had not been completely emptied, 
with a sense of uneasiness and fullness in the hypogastric region. The urine 
undergoes very important and characteristic alterations. At first turbid and 
containing mucus and pus in abundance, it deposits, after standing a short 
time, a thick, tenacious, ropy, or stringy inuco-purulent substance, which, 
when the supernatant fluid is poured off, may be turned out into another 
vessel as a semi-transparent, gelatinous mass, resembling a concentrated in- 
fusion of linseed tea. The chemical constitution of the urine is also altered, 
the secretion becoming alkaline, ammoniacal, and mixed with the inflamma- 
tory products of the mucous membrane, as mucus, pus, vesical epithelium, 
and phosphates. 
Prognosis.-The prognosis in vesical catarrh will depend on the ability of 
the surgeon to remove the cause, and on the duration of the disease. If 
arising from the presence of a calculus, and the patient is not in advanced 
life, there will be a strong probability that on the removal of the stone the 
disease will disappear. If, however, it is the sequel of an old stricture, of a 
sacculated or paralyzed bladder, or of a hypertrophied prostate, the patient 
should be made to understand that nothing beyond palliation is possible. 
Treatment.-In assuming the care of a case of chronic cystitis, the first 
inquiry should be as to its cause. If it is occasioned by stricture, the obstruc- 
tion must be removed as far as possible by the plan of treatment best adapted 
to the particular case; if it arises from stone in the bladder, the calculus 
must be removed. 
Rarely will it be necessary to employ local bleeding, unless an acute ele- 
ment has been engrafted on the chronic, when the abstraction of blood from 
the perineum by leeches will exert a salutary effect. The urine must be ex- 
amined from time to time by the usual test with litmus-paper, so as to main- 
tain the secretion as nearly as possible in a neutral state. This will be done 
by the administration of alkaline remedies, as the bicarbonate of soda or of 
potash, or liquor potassae, when it is acid, and by the use of acids, as nitric 
or nitro-muriatic acid, when it is alkaline. 
When there is reason to believe that a portion of the urinary secretion is 
retained, as must often happen in hypertrophy of the prostate, in a sacculated 
condition of the bladder, or in atony or paralysis of its walls, the soft catheter 
should be used as often as the viscus will allow without adding to its irrita- 
bility, twice in twenty-four hours not being too frequent. 
If the patient is obliged to rise frequently at night, and is unable to obtain 
a sufficient amount of rest, a suppository of opium may be introduced at bed- 
time into the bowel. 
vol. ii.-34 530 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
A vast number of internal remedies are recommended in cases of vesical 
catarrh. Many of these are utterly devoid of virtue, while others may be 
administered with benefit. Those which are entitled to most confidence are 
capsules of tar, tar-water, balsam of copaiba, the terebinthinates, triticum 
repens in decoction (giii in one quart of water, boiled down to one pint, and 
drunk during the day), uva ursi, benzoic acid (grs. ii three times a day), and, 
not the least important, plain water used freely. 
From these remedies one should be selected, and if it fails to afford any 
relief it can be exchanged for another, until the one best suited to the case 
is discovered. I have sometimes derived great benefit from a mixture con- 
sisting of the decoction of uva ursi, liquor potassse, and the juice of bella- 
donna leaves, prepared according to the following formula: 
R Decoct. Uvse Ursi, sjviii; 
Liquor. Potassse, gtt. cxxx ; 
Succi Belladonnas, gtt. xlviii. 
Sig.-Tablespoonful every four or five hours. 
Harlem oil has enjoyed considerable popularity as a remedy in chronic 
inflammatory affections of the bladder, and in some instances may be given 
with decided advantage. 
The introduction of liquids, plain or medicated, into the bladder, either as 
washings or by irrigation, is of very doubtful propriety. Convinced of their 
inutility and of their bad effects, I have for some time abandoned their use, 
and have seen nothing since so doing to lead me to regret this course. From 
irrigation I was disposed at one time to hope that some good might be ob- 
tained by judicious management, and bestowed the greatest possible atten- 
tion upon all the details of the process, having a reservoir constructed, which 
could be kept at any desired elevation, so as to regulate the pressure of the 
fluids, and which was supplied with a lamp and a thermometer, in order to 
preserve the liquid at a proper temperature. This receptacle was placed in 
connection with a double catheter introduced into the bladder, and a constant 
stream allowed to flow through that organ. The liquid used was medicated 
by different articles, as carbolic acid, permanganate of potash, biborate of 
soda, etc. It was not possible, however, to continue the irrigation beyond 
thirty-six hours, as it occasioned so much vesical distress as to demand its 
suspension. 
Those who employ washings do not inject more than one or two ounces of 
liquid at a time, repeating the process until the organ is cleared of all depo- 
sitions, and the injections may be medicated by the addition of alum, biborate 
of soda, morphia, zinc, nitrate of silver, etc., always using a very small quan- 
tity of these articles at first, and increasing the strength as the bladder will 
bear them. 
The operation can be readily done by a double catheter, with a gum bag 
for containing the liquid, the nozzle of which is to be inserted into one of the 
barrels of the instrument. 
In charging the bag with the liquid, the stop-cock is to be opened and the 
air pressed out of the bag while its nozzle is placed beneath the fluid; it is 
then gradually released from the compression of the hand, when the water 
will be drawn up. Before putting the nozzle into the catheter, the bag should 
be pressed until the fluid appears at its extremity, and the injection should 
cease before it is entirely exhausted. In this way the entrance of air into 
the bladder can be avoided. 
Where there is much mucus collected in the bladder after drawing the 
water, any residuum, being liable to act as a ferment and to increase the 
vesical irritation, may be washed out by injecting into the bladder three 
or four ounces of tepid water, or of water containing a few grains of the 
biborate of soda, and allowing it to run out before removing the catheter. 
The most suitable instrument with which to do this is a gum bag with 
a stop-cock and nozzle (Fig. 1315), the latter made to fit the end of the CHRONIC CYSTITIS. 
531 
catheter. It may also be accomplished by gravity, the fluid being poured 
into the gum funnel, which is connected with the cathetei* by a flexible tube, 
all air having been displaced 
before opening the commu- 
nication between the two. 
(Fig. 1316.) 
Heroic injections of the 
nitrate of silver (forty grains 
to the ounce) have been em- 
ployed, and even the applica- 
tion of the solid stick to the 
mucous surface has been prac- 
ticed, especially to that por- 
tion at the neck of the bladder. The strong solutions I have myself tested, 
but without obtaining any marked benefit from their use. On the contrary, 
I have seen the disease greatly aggra- 
vated by such injections. 
Vesical suppositories of morphia 
have been employed to some extent 
by Mr. Harrison, of Liverpool, with a 
view to allay the irritability of the 
organ, and apparently with very good 
effect. The salt is fashioned into the 
proper form by mixing it with cacao 
butter and pressing it into a little 
mould. It is then introduced into 
a canula of the shape of a catheter, 
armed with a stylet. (Fig. 1317.) 
When the point of the instrument 
reaches the neck of the bladder, the 
stylet is pushed forward, which drops 
the suppository into the viscus. 
Opening the neck of the bladder has 
been practiced in some instances for 
the cure of intractable cases of vesical 
catarrh. The design of this procedure 
is to drain the urine out of the bladder 
as soon as it is discharged from the 
ureter, and in this way remove one of 
the principal causes of the perpetua- 
tion of the disease. 
Of 36 cases of cystotomy in the male 
performed for cystitis, and collected 
by Dr. Weir, of New York, who has 
very kindly furnished to me the results of his analysis, 11 died either in 
consequence of causes directly traceable to the operation, or from renal com- 
Fig. 1315. 
Gum bag for injection of the bladder. 
Fig. 1316. 
Apparatus for washing out the bladder by gravity. 
Fig. 1317. 
Mr. Harrison's instrument for conveying suppositories into the bladder. 
plications; 17 were pronounced cured, or so much relieved as to approach a 
cure; 4 were only slightly relieved; and 4 failed entirely. 
In 20 of the 36 cases lateral cystotomy was performed; in 4, bilateral; in 
5, median; and in 7 the form of the operation was not stated. 532 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
In 2 of the recovered cases in which lateral cystotomy was done, the 
median portion of the prostate was also removed; and to this fact was the 
cure ascribed. 
In the 5 median sections the prostate was only dilated, and in 2 the gland 
was, in addition to dilatation, incised to some extent. 
The most that can be said is that the operation is on trial. Statistics 
thus far do not present a very flattering prospect. At present, and contem- 
plating the subject from an anatomical and physiological point of view, I 
seriously doubt if any permanent beneficial results are likely to accrue com- 
mensurate with the risk of the operation,-especially at the time of life at 
which the disease is so often encountered. 
The diet, exercise, and habits of a patient suffering from vesical catarrh 
must be carefully regulated. Stimulating or highly-seasoned food must be 
avoided, milk, animal broths, eggs, and farinaceous articles being most suit- 
able for use. Many persons derive considerable relief from the free use of 
onions, and also from water-cresses. Wines, brandy, whisky, gin, and stimu- 
lants generally are contra-indicated. Old cider, if perfectly sound and not 
too acid, may sometimes be drunk with advantage. The innumerable waters 
whose powers over these affections are so highly extolled possess little supe- 
riority over good water. There are two of these natural waters, however, 
which should not be included in the general condemnation, namely, the 
Rockbridge Alum and the Vichy, both of which enjoy deservedly a good 
reputation as palliative diluents. I have long employed the first, and with 
good results. The body must be wrell protected against the changes of 
weather by wearing, during the winter and spring months, woolen under- 
clothing, and the feet should be kept warm and dry. Warm bathing, by 
keeping the cutaneous glands active, will also conduce to the comfort of the 
patient. Riding on horseback or in rough conveyances, standing long on 
the feet, heavy lifting, and sexual excesses must be avoided. 
The results of inflammatory diseases of the bladder are suppuration, ab- 
scess, ulceration, gangrene, hypertrophy, contraction, and vesical nervousness 
or irritability. 
Suppuration, except as the result of chronic cystitis, is rarely witnessed. 
In malignant growths of the organ purulent matter may be discharged with 
the urine, but it is either the product of a local cystitis, or is derived from 
the granulations of the carcinomatous disease. 
Abscess of the bladder is extremely uncommon. It has occurred in the 
walls of the organ, either on account of a pre-existing chronic cystitis or 
from injury. It may be circumscribed or diffuse, and in either event is an 
exceedingly grave condition. The existence of abscess cannot be determined 
by any means at our command, and, consequently, its diagnosis must be a 
matter of mere conjecture. 
Ulceration is also very unusual, though occasionally met with as the effect 
of long-continued inflammation of the bladder, or of tuberculous or malignant 
disease of the viscus. It may also follow the pinch of a lithotrite or the 
continuous contact of a catheter. 
The signs of ulceration are severe pain, which is referred to a very limited 
region of the bladder, the micturitic paroxysm, due to spasm of the mus- 
cular fasciculi underlying the ulcer, and discharge of blood mingled with 
vesical epithelium and dark fragments or shreds of the mucous membrane. 
The calls to make water increase as the disease progresses, and the suffering 
greatly exceeds that of ordinary cystitis. The general exhaustion is rapid 
and<extreme, and the progress of the disease is to a fatal termination. The 
ulcer presents a round or oval outline; its edges are infiltrated, sometimes 
elevated and at other times depressed. The ulceration is liable, especially 
in the.female, to destroy all the coats of the bladder. HYPERTROPHY OF THE BLADDER. 
533 
The disease has so many features in common with acute cystitis that its 
diagnosis in the male is a matter of much uncertainty. The most character- 
istic differential sign is the presence in the urine of fragmentary shreds of 
the mucous and submucous tissue from the ulcer, which are not met with in 
acute or chronic cystitis. The disease is more easily recognized in the female 
than in the male, as in the former the exploration of the bladder can be made 
with the finger. 
Treatment.-As remedies either administered through the general sys- 
tem or addressed directly to the interior of the bladder do little more than 
assuage pain, it has been proposed by Mr. Guthrie to open the neck of the 
bladder and in this way put at rest its muscular walls, the movements of 
which prevent the cicatrization of the ulcer. The suggestion has been car- 
ried into effect by Dr. Willard Parker, by Sir James Y. Simpson, and by Drs. 
Bozeman, Emmet, Parvin, and others, with the most encouraging success. 
The patients thus treated were all females. But there is no reason, if the 
diagnosis can be established with a moderate degree of certainty, why a 
similar procedure may not be followed by good results in the male. 
Gangrene of the bladder rarely occurs. It has been observed as the effect 
of intense cystitis, extreme distention of the organ, and malignant disease. 
Isolated patches of gangrene at the neck or the bas-fond, of the viscus some- 
times follow both lithotomy and lithotrity. A similar localized form of this 
disease has been known to appeal* during an attack of typhoid fever. If 
in the course of acute cystitis there should occur a sudden cessation of pain, 
great prostration, a very feeble pulse, with a cold, perspiring skin, sunken fea- 
tures, stupor, and hiccough, the existence of gangrene would be highly prob- 
able. Should gangrene be induced by excessive distention of the bladder, 
a rupture of the softened coats may take place, either during fruitless efforts 
to urinate, or from ulceration, and the urine escape into the abdomen, causing 
a fatal peritonitis. The sudden subsidence of the vesical tumor, and the 
existence of intense pain, with a distended and tender abdomen and collapse, 
would sufficiently declare what had happened. Little can be done in the 
way of treatment after such an accident. Opium will be required to alleviate 
suffering, stimulants to counteract the extreme exhaustion, and, if there is 
evidence of urinary extravasation into the cellular tissue of the pelvis, an 
opening should be made through the perineum. 
Hypertrophy is a symptomatic and never an idiopathic condition, but is in- 
duced by any cause which persistently teases the muscular wall into contrac- 
tion. Thus, all inflammatory states of the mucous membrane of the bladder, 
as acute and chronic cystititis, particularly the latter, and all obstructive 
causes, as hypertrophy of the prostate and stricture, which interfere with the 
free escape of the urine, by provoking, through reflex irritation, the frequent 
and vigorous contraction of the detrusor muscle, increase the nutrition of its 
fibres until they attain many times their natural bulk. The fasciculi project 
on the inner surface of the bladder, so as to give to it a ribbed or columnar 
appearance, strongly resembling the column® carne® of the ventricles of the 
heart, which condition can be recognized with great distinctness with the 
point of a catheter or sound when carried into the bladder. (See Fig. 1275.) 
This muscular hypertrophy may be eccentric or concentric. In the first 
form the thickening is attended with general dilatation of the organ, and has 
been induced by obstructive causes; while in the latter form no internal 
resistance whatever has been encountered, the urine being expelled almost as 
soon as it enters the viscus; this is the common attendant of cystitis. This 
latter condition is sometimes designated contracted bladder. One of the evils 
connected with the eccentric hypertrophy is the formation of pouches, which 
are simply herni® of the mucous and cellular coats of the bladder protruding 
between the adjoining muscular fasciculi. These sacs form diverticula for 
the urine, in which decomposition occurs. 534 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Being merely an effect of disease, no treatment can avail for the arrest of 
hypertrophy except such as is calculated to remove the primary or deter- 
mining condition on which its existence depends. 
Atrophy of the bladder is much more common than is generally supposed. 
There is in atrophy not a wasted condition of any single coat of the viscus, 
but all are diminished in thickness and preternaturally soft and unresisting. 
The bladders which I have examined in the dissecting-room and the walls 
of which were preternaturally thin belonged generally to aged persons who 
were thin and emaciated. In paralysis it is likely to occur from defective 
nutrition; and so also in cases where the organ has been over-distended this 
atrophy is the result of a fatty metamorphosis. Hunter and Bonnet have re- 
corded cases of rupture of the bladder, even in young subjects, by the simple 
pressure which was made over the abdominal walls during catheterization. 
In addition to the results of vesical inflammation which have been de- 
scribed, there are others which affect the associate organs. The kidneys 
rarely escape becoming diseased in old cases of vesical catarrh. Thus, we 
often have pyelitis, nephritis, abscesses, and Bright's disease, from the effects 
of which the fatal termination is hastened. 
Vesical Neurosis. 
Under this head I would include those disturbances of function and sen- 
sibility which frequently affect the bladder, which appear to be entirely inde- 
pendent of any co-existing inflammatory element, and which characterize the 
affection described as irritable bladder and neuralgia of the bladder. 
This condition may be idiopathic or secondary to previous disease of the 
organ. The characteristic symptom is frequent urination, the patient being 
obliged to obey the call to pass water immediately on feeling the desire, which 
may return every half-hour or hour. Micturition is usually accompanied 
with pain, sometimes very severe, spasmodic, and burning in its character, 
which is referred to the neck of the bladder, and is not entirely relieved by 
urination. The urine may be perfectly clear, exhibiting no visible signs of 
any change in its constitution, though generally there is an unusual amount 
of phosphates and urates present. Neither may it be materially diminished 
or increased from the normal amount. In other instances, when the disease 
has lasted for some time, the secretion is highly acid, containing a consider- 
able amount of mucous matter, which will be quite noticeable after the water 
has been allowed to stand for some time. A dull feeling of weight is often 
experienced in the perineum and rectum. Usually the individual, if once 
asleep, is not disturbed during the night; and even in the daytime, when the 
mind is earnestly occupied either in business or in amusement, the harassing 
desire to urinate may be absent. The erections are sometimes frequent 
and annoying, and at other times cannot be produced by the most vigorous 
effort of the imagination. In this latter state of the sexual organs it is not 
unusual to find in the urine an abundant supply of crystals of oxalate of 
lime. In addition to the functional disturbance of the digestive organs, in- 
dicated by loss of appetite, flatulence, and constipation, the mental disquie- 
tude which accompanies the affection is generally very marked. The indi- 
vidual loses interest in his business, has little disposition for exertion of any 
kind, and is greatly depressed in spirits. In other cases the dominant symp- 
tom, next to frequent micturition, is severe paroxysmal pain, which, though 
centred at the neck of the bladder, radiates in the direction of the testes, 
anus, perineum, thighs, and loins. There is also a burning sensation along 
the urethra. The urine may be projected violently in spirts, or it may be dis- 
charged in a slow and feeble stream. An attack of this nature will sometimes 
continue for several days, or it may terminate in a few hours, leaving a feeling 
of soreness or tenderness in the perineum, less frequently above the pubes. 
Passing an instrument into the bladder after an attack of this nature, the VESICAL NEUROSIS. 
535 
prostatic part of the urethra will be also found to be in a supersensitive 
state. 
A third variety of this affection is a sequel of acute cystitis or prostatitis, 
in which, although all inflammatory phenomena have disappeared, the bladder 
is left in an irritable state, indisposed to retain more than a few ounces of 
urine at a time, and which probably will be found to contain a little mucus. 
The uneasiness experienced when an attempt is made to resist the inclina- 
tion to micturate does not amount to pain, and after the water has been 
passed the relief is complete for a time. 
Vesical neurosis is not confined to males: females frequently suffer in the 
same way. The attacks are sometimes sudden, without any premonition, 
though oftener their approach is announced by a precedent uneasiness about 
the perineum. 
Young persons and those of mature life, both married and single, the con- 
tinent and the incontinent, are alike liable to this affection. 
Causes.-In the idiopathic variety, these may be gout, rheumatism, cal- 
culus, and miasma; but by far* the most fruitful sources of the trouble are 
masturbation and the sudden interruption of venereal excesses. I have seen 
characteristic examples of this disorder in syphilitic patients. Acid fruits 
will also sometimes develop an attack. The peculiar organization of the 
prostatic part of the urethra rendering this portion of the canal a chief factor 
in that series of acts which culminates in the completion of full coitus, 
together with its rich supply of nerves and the fact that this affection is 
closely associated with disturbances of the sexual functions, would seem to 
indicate that the primary seat of vesical neurosis is located about the pros- 
tate. When following in the wake of a primary cystitis, there is probably 
some vascular congestion concerned in keeping up the irritability. 
Treatment.-A close inquiry should always be instituted, with a view to 
discovei' any tangible causes to which the disease might be ascribed. These 
inquiries will embrace the probability of stone in the bladder, which will be 
settled by the sound, the secret practice of masturbation, the social state of 
the patient, whether single, married, or a widower, antecedent history as to 
arthritic or gouty tendency, the composition of the urine, with any other 
interrogation which may tend to reflect light on the case. Everything, 
therefore, depends on the removal of the cause. If a calculus exists, its ex- 
traction, either by cutting or by crushing, will become necessary. If sexual 
excess or extreme continence has been instrumental in causing the attack, 
moderation or abstinence must be enjoined in the one case and marriage in 
the other. 
When the vesical trouble is associated with pain, swelling, and redness 
of a joint, its gouty or rheumatic origin may be confidently assumed, and re- 
lief will be obtained by a mercurial purge, followed by the exhibition of full 
doses of the iodide of potassium, with the wine of the root of colchicum. 
Miasmatic causes are to be inferred when the attack comes on at definite 
periods, and when there has been a previous exposure in unhealthy localities: 
in these cases quinine and arsenic are the remedies which promise relief. 
When there has been a history of constitutional syphilis, full doses of the 
iodide of potassium will be found to act like a charm. One of the severest 
cases of this affection which I have ever witnessed, and which had baffled all 
previous treatment, was promptly cured by twelve-grain doses of this salt. 
When an examination reveals the presence of oxalate of lime in the urine, 
it will be necessary to regulate the diet, and, in order to correct the vice, to 
administer nitro-muriatic acid. 
In young females this functional disturbance is often associated with irreg- 
ularities of the menses, which will be best corrected by a course of iron, 
quinine, and strychnine. During the severity of an attack the pain must be 
relieved by suppositories of opium and extract of belladonna, or by an enema 
of laudanum and the use of the hot hip-bath. When the irritability of the 
bladder has succeeded to an attack of cystitis, there must be enforced the 536 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
strictest attention to diet, directing chiefly milk and farinaceous prepara- 
tions of food and the avoidance of alcoholic beverages, of horseback-riding, 
and of venereal excesses. The cold hip-bath will constitute an important 
adjuvant to the treatment. 
After the most rigid search into every possible cause which may be con- 
cerned in vesical irritability, there will still remain a certain number of cases 
the causes of which will elude the most critical research ; and though doubt- 
less there is a physical basis for the disturbance, yet its chief importance 
has grown out of habit or from psychological peculiarities. I have been able 
in such cases to effect complete and permanent cures by instructing the pa- 
tient to commence a work of bladder education ; that is, not to yield to the 
first desire to urinate, but to resist thejnclination, and thus prolong the period 
between the micturitions, seven or eight minutes at each time, until the 
mastery over the rebellious organ has been obtained. 
A fistulous opening between the bladder and the rectum may originate in 
various ways,-sometimes as an effect of chronic inflammation, more com- 
monly from a wound being inflicted on the bowel during that stage in the 
operation of lithotomy when the prostate is being divided. 
A calculus may cause ulceration in the vesico-rectal walls and terminate 
in a fistula. The same result has followed tapping the bladder through the 
rectum. A sharp-pointed foreign body may become arrested in the rectum 
and ulcerate forward into the bladder. I removed a calculus from the blad- 
der of a patient which contained as a nucleus quite a large raisin. He had 
been suffering for three years with a recto-vesical fistula, caused by a chicken- 
bone, which, in passing along the bowel, had become arrested, and finally 
entered the bladder by ulceration. The bone, which was one inch and a half 
long, was discharged through the urethra several months before the operation 
of lithotomy. Cancer of the rectum, in the progress of its destructive ulcera- 
tion, not unfrequently destroys the walls of the bladder and forms a fistulous 
opening between the latter and the bowel. A similar opening may be caused 
in the female as the result of pelvic cellulitis. 
The signs of recto-vesical fistula are usually very obvious, air and faeces 
passing into the bladder and escaping through the urethra, and urine enter- 
ing the rectum. 
Treatment.-When the fistula is located some distance up the bowel and 
communicates with the bas-fond of the bladder, it will often defy all plans 
of treatment. When lower down, at the neck of the bladder, or in the 
prostate body, a cure may sometimes be accomplished. The means usually 
employed for the purpose are caustic, the actual cautery, and closure by 
sutures. 
The caustics which procure the best results are the acid nitrate of mer- 
cury and nitric acid, either of which can be most conveniently applied to 
the abnormal opening by the use of a silver probe somewhat bent at the 
extremity, or by a small glass rod. The instrument for using the caustic 
should pass into the fistula, and not be merely brought in contact with its 
external orifice. Before using the caustic it is necessary to have the bowel 
thoroughly cleared out. The patient should be placed on the knees and 
elbows, with the pelvis well raised, in which position the fistula can be best 
exposed by introducing into the rectum a duck-bill speculum. After the 
cauterization the bowels must be kept quiet for seven or eight days by the 
use of opium, after which they can be opened and a second application made 
of the caustic. If, after four or five repetitions of this agent, no progress is 
made towards a cure, this method of treatment should be abandoned for the 
cautery, the most eligible apparatus for the purpose being that of Paquelin. 
The galvano-cautery will also answer very well. In the absence of either, 
a fine olive-pointed hot iron will fulfill the object in view. The application 
Recto-Vesical Fistula. HAEMATURIA. 
537 
should be made through a cylindrical speculum having an oblong fenestra 
in its walls. 
When the fistula is low down and can be readily exposed by means of the 
duck-bill speculum, it will be better to proceed at once to pare the edges of 
the opening and bring the sides together with silver sutures, securing the 
latter by the shot clamp. During the treatment the patient should lie on 
his breast, in which position the urine must also be frequently passed. The 
sutures are to be removed on the seventh or eighth day, and two days later 
the bowels can be opened. Should the patient have any trouble in passing 
his water, the soft catheter can be introduced into the bladder several times 
during the twenty-four hours, for the more empty the viscus is kept the 
greater the probability of success in the treatment. 
Vesico-Pubic or Inguinal Fistulae follow wounds and abscesses in the cellular 
tissue around the bladder and also in its walls. In cases of cystocele which 
have been mistaken for abscess or cysts and laid open, such fistulse will be 
likely to form. There may be several openings in the abdominal region, 
though but a single one in the bladder. A lady under my care had, in conse- 
quence of a pelvic cellulitis terminating in suppuration, five inguinal hypo- 
gastric fistulfe on the right side communicating with the bladder. Though 
of over one year's standing, they had, at the time of my last visit, all closed 
except two by the simple expedient of emptying the bladder while lying on 
the left side. The remaining fistulfe were rapidly diminishing. 
The treatment consists in keeping the bladder empty by frequently uri- 
nating, and in a position of the body which will divert the urine from the 
abnormal opening. In some instances frequent catheterization will be prefer- 
able to voluntary micturition, as the muscular walls of the organ will be less 
disturbed by the former. 
fistula will be considered under the surgical diseases of 
women. 
Varices. 
True varices are very rarely seen in the veins of the body or fundus of the 
bladder, though the serpentine form of the vessels would appear to be favor- 
able to such dilatations. At the neck of the organ and around the prostate 
a condition of this kind is not unusual. Morgagni and Chopart have described 
such enlargements of these vessels, and I have myself seen them similarly 
dilated and convoluted in the cadaver, and in one instance was able to make 
successfully an injection of these canals. Any obstruction, as stone in the 
bladder or hypertrophy of the prostate body, will, by causing vascular con- 
gestion and by interrupting the free return of the venous blood, tend to 
induce this condition of the vessels. 
Doubtless some of those hemorrhages which are encountered in prostatic 
diseases, or which follow the lateral operation for stone, may be properly 
referred to a varicose state of the prostatic and vesical veins. 
Hsematuria. 
Haematuria is a term used to express the presence of blood in the urine, 
but has no reference to the source from which the hemorrhage comes, and 
is, therefore, employed in a generic sense. The kidneys, the ureters, the blad- 
der, and the urethra being continuous portions of the genito-urinary appa- 
ratus, blood may come from any part of this extended surface and appear in 
the urine. At present it is only with hemorrhage from the bladder that we 
have to deal. 
Vesical hemorrhage may be idiopathic, traumatic, or pathological. Persons 
somewhat advanced in life suffer more frequently from this than the young 
or the middle-aged. The causes of idiopathic vesical hemorrhage are altera- 
tions in the structure of the blood, obstruction to the circulation through 
the ascending vena cava, and the action of certain drugs. 538 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Under the first, or blood-changes, may be mentioned those cases of bleeding 
from the bladder which are seen to accompany purpura, scurvy, typhoid, and 
some exanthematous diseases. No visible lesion of vessels can be detected 
in these cases of hemorrhage, the blood appearing by an exudation from the 
vessels of the mucous membrane. 
Under the head of obstructive causes will come enlargement and indurations 
of the liver, and abdominal tumors. These, by pressing on the vena cava, 
prevent an uninterrupted flow of venous blood to the right side of the heart, 
and consequently cause an over-distended condition of the vesical veins. 
The medicinal substances which act by producing irritation and congestion 
of the mucous membrane of the neck of the bladder, and not infrequently 
the loss of blood, are cantharides and the terebinthinates, particularly oil of 
turpentine. 
The traumatic causes most frequently concerned in producing vesical 
hemorrhage are stone, the rough use of the catheter, of the lithotrite, or of 
the sound, blows or falls on the lower part of the abdomen or on the pelvis, 
wounds, incised, gunshot, or punctured, sexual excesses, etc. 
The pathological causes are ulceration, cancer, and varices, and finally, in 
certain Eastern countries, vascular congestion caused by a peculiar parasite 
-the Bilharzia hcematobia-which makes its habitation in the coats of the 
bladder. Dr. Barry, of Dublin, has recorded the case of a man who bad suf- 
fered for several years from pain and vesical irritation, attended with the 
discharge of bloody urine, who promptly recovered on passing from the 
bladder a worm one inch in length. Mr. Lawrence mentions a similar case 
in a female twenty-four years old, who, at different times in the course of a 
year, passed from the bladder between eight hundred and one thousand 
worms. 
Vesical hemorrhage is sometimes vicarious, designed in women to compen- 
sate for the suppressed menstrual flow, and in men for the sudden arrest of 
hemorrhoidal bleeding. The amount of blood which may appear in the urine 
is subject to great variation. It may be so small in quantity as to be detect- 
able only by a microscopic examination, or it may be so great as to fill the 
bladder with coagula. The presence of even a very little blood imparts a 
smoky or mahogany-brown color to the urine. 
Diagnosis.-Bloody urine always creates alarm, and persons so affected 
apply early for medical counsel. Occasionally unnecessary anxiety is expe- 
rienced by individuals who find their urine to have a very high color, and 
suppose the tint to depend on the presence of blood, when it is entirely 
free from that fluid. There are some substances-for example, the fig cactus 
-which, when eaten, impart to the renal secretions a color closely resembling 
that of blood; the same is true of santonin when used internally: conse- 
quently the representations of patients must never be taken on a subject of 
this nature without being confirmed by medical examination. 
Urine containing blood will always be found to be albuminous. As the 
extended mucous tract belonging to the genito-urinary organs may furnish 
a hemorrhage at any point from the kidneys to the urinary meatus, it is 
not always easy to ascertain the true source of blood which appears in the 
urine. 
In cases of penetrating wounds, fractures, and other injuries of the pelvis 
when the violence can be traced directly to the bladder, or when, after the 
use of instruments in the viscus, bleeding follows, there will be little difficulty 
in conjecturing its source. But when no such clue is possessed, the solution 
of the difficulty is not always an easy one. In instituting an inquiry to 
clear up the obscurity, it will be necessary to proceed on the principle of 
exclusion. Renal hsematuria is usually preceded by a history of kidney 
disease, as albuminous urine, casts of the uriniferous tubes (fatty and gran- 
ular), oedema, headaches, and retinal changes; or if from a renal calculus 
lodged in one of the infundibula or in the pelvis of the organ, there will 
have been pain in the back, pain along the course of the ureter, or in the HJEMA TURIA. 
539 
testicle, and probably an attack of renal colic with blood-casts and abundance 
of spherical epithelium. When the hemorrhage is renal and has followed 
an injury about the loins, as in lifting heavy weights, there is more or less 
uneasiness experienced in the lumbar region. The blood which reaches 
the bladder from the kidney, entering the former viscus in drops and rarely 
passed pure, but in clots, is generally uniformly diffused through the urine, 
so as to impart a dark, smoky appearance to the secretion. Exceptions to 
this will be noticed in the hemorrhage following malignant growths of the 
kidney, and often after severe traumatic violence. In hemorrhage suspected 
to be from the prostate, we should expect to find the gland enlarged, prob- 
ably tender, the patient over fifty years of age, and a previous history of 
bladder irritation. 
If stricture of the urethra is the cause of bleeding, there will have been 
experienced the signs of obstruction to the free flow of urine, a diminished 
stream, and the usual information may be acquired by the use of the bougie. 
Clots are often discharged in such cases moulded into cylinders having the 
form of the urethra. Hemorrhage from the ureters will probably be the 
result of an unsuspected calculus, and is marked by intense and sudden pain, 
radiating towards the back, thighs, and testicles, with retraction of the latter, 
and accompanied by nausea, vomiting, and prostration. 
The sudden subsidence of these symptoms in the event of the calculus 
passing into the bladder will furnish additional and decisive evidence. 
If, therefore, none of the characteristics indicated are present in a case 
of hiematuria, there will be strong reasons for believing that its source is 
the bladder. There will be additional and certain confirmation if, on explora- 
tion of the viscus with the sound, a stone or some morbid growth is detected, 
or if the urine contains a large amount of muco-pus, evidence of chronic 
cystitis. 
When the amount of blood is considerable and derived from the vessels 
near to the neck of the bladder, or from the prostate body, the coagula col- 
lect in the bladder, and, being dissolved by the urine, are discharged in mic- 
turition, the mixture presenting very much the appearance of coffee-grounds. 
When hajmaturia is produced by the presence of a malignant growth in 
some part of the urinary tract, not unfrequently the tumor may be discovered 
by a careful examination made in the hypogastric, the lumbar, or the iliac 
region, or through the rectum. Even when not appreciable to the touch, 
such disease will sometimes be revealed by shreds of decomposed tissue, and 
by the signs of failing health. 
Important information as to the source of hamaturia may also be obtained 
by inspecting the blood-clots which may be passed. These will often assume 
the form of the canal from which they proceed. 
Mr. Hilton has given considerable importance to this subject. 
By floating the clot in water any peculiarities of form which it may pos- 
sess will be unfolded and displayed. Coagula from the bladder are represented 
as being flattened, circular, and irregular in their outline, with beveled and 
serrated margins. Long, slender, worm-like coagula indicate that the clots 
are derived from the ureter; when fashioned into round cylinders, they prob- 
ably are moulded in the membranous or spongy urethra ; and when formed 
in the prostatic sinus, they are fusiform and flattened. 
In cases of hemorrhage excited by the presence of the Bilharzia hcematobia, 
the nature of the cause may be detected by finding in the urine the ova or 
embryos of these parasites. 
Treatment.-In the treatment of hemorrhage from the bladder, it is all- 
important that the cause on which it depends shall be ascertained. When 
it arises from stone, its extraction constitutes the remedy; when it has been 
caused by the rough use of instruments and caustics, rest in the recumbent 
position, with ice applied to the perineum or over the hypogastrium, will 
generally arrest the flow. 
When the bleeding is idiopathic, in addition to rest and recumbency it may 540 
INJURIES AND DISEASES OF THE GENITO-URINARF ORGANS. 
be necessary to administer haemostatics, gallic acid, acetate of lead, alum, 
creasote, aromatic sulphuric acid, tincture of the chloride of iron, Monsel's 
solution of iron, fluid extract of ergot, and turpentine being the most valu- 
able. The last two may be administered together, and are particularly effi- 
cacious. Fifteen drops of the fluid extract of ergot and six drops of the oil 
of turpentine may be given in some mucilage once every hour until the 
desired effect is produced. Small pieces of ice cut into a conical form and 
introduced into the rectum will also be found useful; and the same is true 
of the ice-bag applied to the perineum. 
As in other forms of hemorrhage, so in this, opium will be found to be of 
great value, and may be given either by the mouth oi' by the rectum in the 
form of suppositories. 
In those cases of vesical hemorrhage in which there is a constant passive 
leakage, and which resist the remedial measures already indicated, injections 
into the bladder of Monsel's solution of iron (twenty drops of the iron to one 
ounce of water) will exert a salutary effect. Nitrate of silver has also been 
employed by Thompson with a good effect in the proportion of one grain of 
the salt to an ounce of distilled water. 
When the hemorrhage proceeds from a vesical growth, and is of a nature 
to admit of removal, it should be removed by the median perineal cystotomy 
in the male, and through the dilated urethra in the female. In two instances 
I have twisted off and extracted large papillary fibromata in this way from 
the female bladder, with the effect of giving long periods of relief. Where 
from repeated attacks of vesical hemorrhage the vessels have been drained 
and anjemia induced, preparations of iron will be demanded, as the tincture 
of the sesquichloride or of the pernitrate, not only on account of their tonic 
effects, but also foi' theii* astringent properties. Nor must the proper regu- 
lation of the diet be overlooked in this form of heematuria. Stimulating 
articles of food will be out of place, and solid nourishment will be preferable 
to liquid, except where there is much exhaustion, when milk and animal 
broths will be required to replenish the vessels. 
When stimulants are required, the red wines, being rich in tannic acid, 
should be preferred. 
When coagula accumulate in the bladder, there should be no premature 
meddling or over-anxiety to dislodge the blood from the bladder by the use 
of the catheter. Instrumental interference may open anew the vessels which 
have ceased to bleed. 
The urine is an expellant of these blood-clots, and in time will interpene- 
trate the latter and dissolve them sufficiently to admit of their being dis- 
charged as a dark, sanious-looking fluid. 
When, however, the bladder becomes much distended by the accumulation 
of blood, and is unable to free itself, resort must be had to the large catheter 
with which to break up the coagulum, and through which, by passing cold 
water and applying suction, the organ may be unloaded. 
Should all measures fail to effect the end in view and the symptoms con- 
tinue urgent, the surgeon would be justified in opening the bladder, as in the 
lateral operation for stone, and clearing out its contents with the scoop and 
by repeated washings. 
Adynamia, or loss of power in the walls of the bladder, wdiereby the organ 
is rendered unable to expel its contents, may arise from centric or from 
eccentric or peripheral causes. 
When from the former, that is, from some lesion of the brain or the spinal 
marrow, it is usually termed paralysis; when from the latter, or from causes 
affecting the conducting properties of the nerves, atony. 
It is necessary, in treating of this subject, to have clear and well-defined 
ideas with regard to certain expressions in common use, as from the vague 
Adynamia and Paralysis of the Bladder. ADYNAMIA AND PARALYSIS OF THE BLADDER. 
541 
manner in which they are employed they are liable to convey erroneous im- 
pressions. First, there may be an entire inability of the bladder to expel its 
contents without any paralysis whatever, as in cases of obstruction from re- 
flex contraction or spasm of the sphincter vesica?, consequent on the ligation 
of hemorrhoids, or from an irritable stricture, or from ascarides, or from hy- 
pertrophy of the prostate. But it will be observed that in such a condition 
the difficulty does not result from the want of power, but from causes which 
render its exercise futile. Such a disability constitutes an example of ob- 
structive retention. Again, retention may occur from psychical causes, in which 
there is an absence, not of power, but of its co-ordination. It may also arise 
after an amputation or a fracture of the leg, when the inability to urinate is 
in great measure to be attributed to position of the body, the act requiring 
for its execution a new and untried exercise of muscular power. 
The peripheral or eccentric causes which produce partial or complete loss 
of power in the walls of the bladder are the following: 
1. Over-distention.-An individual may from the force of circumstances, 
from feelings of modesty, or from causes which lower the sensibility of the 
brain to the ordinary wants of the organs (as intoxication), allow the 
bladder to become so distended with urine that the nerves, in consequence 
of the pressure and stretching to which they are subjected, are rendered unfit 
for transmitting those motor impulses to its walls which are necessary for 
their contraction. This loss of power from peripheral causes is frequently 
met with in aged persons, especially in those whose occupations have been 
of a sedentary nature. Book-keepers and men of literary pursuits, absorbed 
with their calculations and studies, often become insensible to the usual 
promptings of the organ, and allow the inordinate accumulation to be re- 
peated until there follows a permanent atony. In addition to the internal 
pressure from the urine, there may be pressure from without, inducing such 
lesion of the nerves of the bladder as will destroy the contractility of its walls 
for a long time, as when a blow or other injury is received in the hypogastric 
region, or when an accoucheur, during the delay of the foetal head in its 
transit through the pelvic basin, allows the bladder to become distended with 
urine. 
The evil resulting from over-distention of the bladder does not always ter- 
minate with the removal of its contents. This may be followed by hemorrhage, 
especially when the whole of the accumulation is removed at once, by cys- 
titis from the decomposition of urine, and by an enervation which, disturbing 
the nutrition of the organ, inaugurates fatty degeneration of its muscular wall. 
This atrophy of the walls of the bladder is liable to occur under other con- 
ditions than those of distention. It may be a part of that general wasting 
which marks the decay of the human body in advanced life, and it may also 
follow in consequence of the pressure of abdominal or pelvic tumors on the 
principal blood-vessels or nerves which supply the bladder, thus inducing 
atrophy by interrupting the necessary supply of blood or nerve-force. 
2. Cfen/rze paralysis arises from causes affecting either the brain or the 
spinal marrow. Thus, after concussion, compression, meningitis, encephalitis, 
myelitis, fractures of the vertebrae, syphilitic and other deposits, there may 
be a complete or a partial loss of power in the bladder. Even where no 
actual lesion of the cerebro-spinal axis exists, there may be present a paral- 
ysis from functional disturbance of these centres of nerve-power. Examples 
of this nature are witnessed in low forms of fever, in which, partly from 
the apathetic stupor of the mind, the result of a vitiated blood circulating in 
the brain, and partly from a defective nerve-energy, the patient is not quick 
to recognize the urgent necessity of the organs, and the bladder is allowed to 
become distended. These cases are often overlooked by the careless or igno- 
rant physician until the life of the patient is placed in the greatest jeopardy. 
Belonging to the same category of functional disability are those cases of 
vesical paralysis which result from exhaustion of nerve-power, as from great 
sexual excess, in which the constantly repeated demands or drafts on the 542 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
source whence the genito urinary apparatus is endowed with power have 
exhausted the supply. 
Paralysis occasionally follows the use of certain drugs, as hyoscyamus and 
belladonna. 
In most instances of paralysis of the bladder, especially from centric 
causes, the over-distention is after a time followed by dribbling,-a fact which 
should not escape notice, as it might lead to serious consequences if the 
physician supposed such a condition to be incompatible with an undue 
accumulation of urine in the bladder. 
In consequence of the manner in which the bladder is supplied with nerves, 
the body of the organ may be paralyzed and its neck remain unaffected. 
Or the neck may be the seat of the paresis and the body retain its functional 
power. In the former case there will be retention of urine, in the latter there 
will be incontinence. 
Whatever may be the origin of the paralysis, whether from centric or other 
causes, it is soon succeeded by alterations in the constitution of the urine, 
in which the secretion becomes alkaline, muddy, emits an ammoniacal odor 
from the decomposition of urea, and is loaded with amorphous phosphates. 
These, reacting on the mucus of the bladder, not only provoke a chronic or 
catarrhal cystitis, but also lay the foundation for calculous concretions, incrus- 
tations of the lining membrane of the bladder, ulceration, and even slough- 
ing of its coats. The general health soon suffers from the absorption of the 
constituents of the urine, which, circulating in the blood, seriously impair the 
nutrition of the body, and exert a poisonous influence on the skin and on 
the brain, as seen in the cutaneous eruptions which break out over the sur- 
face of the body, and in the fatal coma which occasionally supervenes. 
The signs of an over-distended bladder are sufficiently obvious to prevent 
any mistake from being committed. 
A tumor or swelling having a regular outline will occupy the hypogastric 
or the umbilical region, which on percussion yields a dull or flat percussion- 
note. 
When the paralysis has been induced by peripheral causes, the accumula- 
tion or distention will have been marked by uneasiness, restlessness, pain, 
and fullness, with frequent but ineffectual efforts to urinate. 
Diagnosis.-The diagnosis of paralytic or of adynamic retention from ob- 
struction, and of reflex retention, may be easily established by the use of the 
catheter. In the former the instrument will pass readily into the bladder 
without encountering any opposition. The escape of the urine will be unlike 
in the two conditions. In the former the water, not being propelled by the 
contraction of the walls of the bladder, will flow in a slow stream, while in 
the latter (reflex retention) it will be discharged forcibly, even impetuously. 
Prognosis.-This can be formed only after a careful consideration of the 
causes on which the disability depends. When produced by carelessness or 
supersensitiveness, and in a young person, and when early relieved, the 
muscular tonicity will in all probability be quickly recovered and no incon- 
venience will follow. 
In persons somewhat advanced in life, and in whom the adynamic state 
of the organ has been slowly increasing, or who have had several attacks of 
retention, the outlook will be unfavorable. When the enervation or paralysis 
is the effect of exhaustion, as in typhoid fever, or from simple concussion of 
the cerebro-spinal axis, the power will return with convalescence. When 
following compression of the brain from depressed bone, the elevation of 
the fragments is generally followed by a recovery of muscular power in the 
organ. The most unpromising cases are those which have been produced 
by lesion of the brain or of the spinal marrow, recovery seldom taking place. 
Treatment.-The indications in the treatment of an atonic or a paralyzed 
bladder are, first, to remove as quickly as possible the contents of the viscus, 
and, secondly, to endeavor to restore the lost muscular contractility. 
The use of the catheter will accomplish the first, and it will be necessary INCONTINENCE OF URINE. 
543 
to repeat it three or four times in the twenty-four hours. By this means the 
walls of the organ are preserved in a relaxed or collapsed state, which will 
conduce to their recovery. Besides this there is another very important 
end secured, which is to prevent those changes which are certain to follow 
the presence of residual urine, which is a fruitful source of evil, both local 
and general. When the distention is great, the removal of the watei* 
should be effected gradually, and not all at one time. A contrary course 
may induce fatal prostration or severe hemorrhage. Even when patients 
have recovered what appears to be a fair power over the bladder, there 
will often remain a variable quantity of urine, from one to several ounces, 
which cannot be detected in any other way than by introducing the cath- 
eter. As long as this is the case there is danger, and the instrument 
should be used. The soft catheter should always be employed, as by its 
flexibility the bas-fond of the bladder, where the last pool of urine lies, 
with its sedimentary deposits, can be most satisfactorily reached. As the 
necessity for catheterization will often exist for a long time, the patient 
must be instructed in the use of the instrument; and, as in many cases the 
urethra possesses little or no sensibility, the advantage of the soft catheter is 
obvious, since the canal is not likely to be damaged in its introduction. While 
it is important to remove the urine by instrumental interference, it is at 
the same time possible to carry even this measure too far. The bladder, if 
constantly helped in this way, may learn to rely on artificial assistance. 
Whenever, therefore, the organ has recovered to a reasonable degree the 
power to contract on its contents (as will appear by the force with which the 
urine flows), the instrument should be employed less frequently, and the 
patient urged to exercise all possible voluntary power to empty the viscus. 
This very act of volition will impart a new stimulus to the organ and hasten 
the cure. 
In addition to the local treatment, benefit will accrue from the exhibition 
of internal remedies. In many cases of paralysis of the bladder the deter- 
mining cause affects to some oxtent the intestinal tract, thus favoring the 
formation of fecal accumulations. It will be desirable, therefore, to secure 
proper alvine evacuations by the administration occasionally of gentle ca- 
thartics. They will also be indicated in inflammatory conditions of the brain 
and spinal marrow or their membranes. When the necessity for a general 
tonic exists, the tincture of the chloride of iron and quinine may also be ad- 
ministered. When there is reason to believe that the offending cause is a 
gummy tumor, or some other morbid change in the cerebral or spinal centre, 
iodide of potassium, with or without mercury, will be demanded. When 
the cause which was actively concerned has been removed, and the vesical 
disability appears to depend on inertia of the muscular walls of the organ or 
of the centre from which they are energized, strychnine and ergot may be 
given, either singly or conjointly, with advantage (strychnine has been 
injected into the bladder in a few instances, it is said, with a good effect). 
Electricity has also been applied by passing the current directly through the 
walls of the bladder, one insulated electrode being introduced into the bladder 
after the urine has been removed, and the other electrode, provided with a 
moistened sponge, being applied alternately over the hypogastrium and the 
lumbar region, or over the perineum. Occasionally the second electrode is 
introduced into the rectum,-of course without the sponge. 
In addition to these measures, blisters over the lumbar and sacral regions, 
and the cold douche applied to the back, to the perineum, and to the lowei* 
part of the abdomen, will be valuable adjuvants. 
Incontinence of Urine. 
Incontinence of urine may exist at any period of life, though most common 
in children and in aged persons. It is subject to great variations; the urine 
may escape as fast as it is secreted, or it may be retained until several ounces 544 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
accumulate, and then be discharged guttatim or in a feeble stream: occa- 
sionally it is projected with some force in jets. 
Very frequently in children and in youths the incontinence or enuresis 
exists only in the night and during sleep, when it is termed nocturnal incon- 
tinence. 
The causes of incontinence are traumatic, mechanical, chemical, inflammatory, 
and reflex. 
1. Traumatic incontinence may result from a fistulous opening remaining 
after the operation for stone, oi' from the presence of a recto-vesical or a 
vesico-vaginal fistula. The same defect may follow a blow or other injury 
applied over the lumbar or the sacral region. In women it may be caused 
by the foetal head pressing the bladder for a long time during a protracted 
labor. The displacement or crumbling of the vertebras in children suffering 
from Pott's disease of the spine, by damaging the medulla spinalis or the 
nerves which go to form a part of the vesical plexus, will also render the 
organ incapable of retaining its contents. The treatment of traumatic in- 
continence will be indicated by the cause. If from fistulae, they must be closed 
by an operation, or by other measures, when practicable; if from violence, 
as blows, kicks, falls, etc., rest, and after a time the use of strychnia, will 
be of great advantage; if from caries of the vertebrae, suspension of the 
body and the application of a plaster or leather jacket will afford the fairest 
prospect of relief. 
2. Mechanical incontinence often follows hypertrophy of the prostate body, 
more particularly when the disease affects the middle lobe of the gland, 
or when a myomatous fibroma is developed in its structure. Either of these 
growths, projecting into the neck of the bladder, serves to open its canal by 
acting as a wedge. 
The frequent introduction of large bougies into the bladder may be fol- 
lowed by a patulous state of the neck of the viscus, which will allow more 
or less dribbling. The mechanical distention of the bladder consequent on 
obstruction, either from enlargement of the prostate or from urethral stric- 
ture, may also so weaken the walls of the organ as to induce a dribbling or 
an overflow from paresis of the sphincter vesica;. 
When the incontinence is the result of morbid growths dilating the neck 
of the viscus, the case is not amenable to treatment; a spontaneous relief is 
in rare instances obtained by a change in the direction of growth of the 
tumor, by which the latter is drawn away from the orifice of the urethra. 
Incontinence following the use of large bougies in the treatment of stricture 
should warn the surgeon against extreme dilatation. 
3. Chemical incontinence is the result of changes in the constitution of 
the urine, in which the secretion becomes intensely acid, or is loaded with 
crystals of uric acid or oxalate of lime, the irritation from which on the 
mucous lining of the bladder causes contraction of the detrusor muscle and 
a frequent expulsion of the urine. This annoying condition can generally 
be corrected by the exhibition of alkalies, in order to remove the acidity of 
the secretion, by carefully regulating the diet so as to correct any error in 
the process of digestion, and by the subsequent administration of tonics, 
particularly the mineral acids, as nitric or nitro-muriatic acid. In such cases 
a decided improvement will often follow the use of a pill consisting of pepsin 
and strychnia, five grains of the former and one-thirtieth of a grain of the 
latter, taken on sitting down to meals. 
4. Inflammatory incontinence is that form of enuresis which is produced 
by structural changes in the mucous membrane and the muscles both of 
the bladder and of the urethra. Thus, a rough stone is capable of creating 
a cystitis which will render the bladder perfectly intolerant of the presence 
of urine. The same effect may follow the extension into the viscus of a 
gonorrhoeal urethritis, or of a prostatitis, or tubercular or syphilitic ulceration 
of the neck of the organ. 
Inflammatory fullness of the vessels, by teasing the walls of the bladder, INCONTINENCE OF URINE. 
545 
induces concentric muscular hypertrophy, which, by diminishing the cavity 
of the organ, renders it unable to retain more than a small quantity of urine 
at a time. 
Again, incontinence may follow those inflammatory changes which are 
produced in the compressor urethne muscle by strictures situated in the 
membranous portion of the urethra, by which that muscle is converted into 
dense fibrous tissue, and consequently becomes useless to guard the canal 
against the involuntary intrusion of the urine. The treatment must be 
directed to the subjugation of the inflammation by rest in the recumbent 
position, leeches to the perineum, the hot hip-bath, and anodyne injections 
or suppositories. 
5. Reflex incontinence arises from a variety of causes, among which may 
be named a contracted prepuce, collections of smegma behind the corona of 
the glans penis, rectal irritation the result of worms or polypi, change in 
the quality of the urine, masturbation, etc. Many cases of juvenile incon- 
tinence are due to the operation of some one of the above causes, and are 
promptly and radically cured by their removal. Boys are more frequently 
affected than girls. 
During my connection with the board of management of the House of 
Refuge in the city of Philadelphia, urinary incontinence became so general 
among the boys that the attention of Dr. Addinell Hewson, the medical 
attendant of the institution, was called to it, and he made a very thorough 
inquiry into the subject. Of 75 boys affected with enuresis, 34 were negroes, 
their ages varying from seven to eighteen. A very large proportion of these 
children belonged to the unthrifty, neglected, and destitute class, and many 
of them were far from being vigorous, healthy lads. One-third of the number 
suffered from ascarides, 20 from constipation, a few had herpes, and 18 ac- 
knowledged the habit of masturbation; there were reasons for supposing 
that almost all were addicted to this vice. The incontinence rapidly dis- 
appeared under a regulated diet, and the use of laxatives, succus belladonme, 
alkalies, and turpentine, according to the individual necessities, with the aid 
of a little monitory discipline. 
There are, however, a considerable number of cases of this troublesome 
affection, in both boys and girls, which cannot be traced to any of the afore- 
mentioned causes, and which are most probably dependent on peculiarities 
of a constitutional nature, in which the brain or spinal marrow participates. 
They are generally met with in young boys of fair complexion, feeble or- 
ganization, and nervous excitability, to whom the disability clings, in defiance 
of all treatment, until the period of puberty, or for some time after. Many 
persons who suffer from seminal emissions have been victims of urinary in- 
continence previous to puberty; and, as the nerves which supply the genital 
and the urinary organs are so closely related, it is reasonable to suppose that 
the reciprocal influence of the two must be very great. 
In addition to the varieties of urinary incontinence already named, there 
are occasional cases of the affection, generally in adults, in which vesical dis- 
ability appears to depend on miasmatic causes, the inference of such an 
origin being drawn from the periodicity of the attacks and the existence of 
chills and rigors. These cases require the use of full doses of quinine. 
Treatment.-In the treatment of juvenile incontinence a most careful 
inquiry should be instituted with a view to discover if there exists any local 
cause likely to produce or perpetuate the affection. If there is present a 
contracted prepuce, circumcision or incision will be required ; if the lower 
bowel is infected with ascarides, injections of carbolic acid and turpentine, or 
of salt and water; if there is constipation, it must be relieved by the use 
of saline laxatives; if the urine is unduly acid, it must be corrected with 
alkalies, as the bicarbonate of soda; if, on exploring the bladder, a stone is 
discovered, relief can be obtained only by its removal; and if the digestive 
organs are deranged, and there are signs of defective nutrition, iron, strych- 
nine, and pepsin, separately or in conjunction, will be required. With a view 
vol. ii.-35 546 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
to lower the sensibility of the bladder and the cerebro-spinal axis, no remedy 
is so deserving of trial in urinary incontinence as belladonna. From three 
to five drops of the tincture, or the same amount of the juice of the leaves, 
may be given to a child four or five years old three times a day. A com- 
bination of this drug with the bromide of potassium will sometimes prove 
more efficacious than the belladonna alone. A pill or emulsion consisting 
of camphor and belladonna, given three or four times daily to patients under 
eight or ten years of age, will, in some instances, exert an excellent effect : 
gum camphor, gr. %; extract of belladonna, gr. -N; to -j-. In pale, weakly, 
and strumous children cod-liver oil and the syrup of the iodide of iron will 
be found useful. 
In addition to these remedies, cold hip-baths or douches of cold water will 
tend to lower the sensibility of the neck of the bladder, by imparting general 
tone to the pelvic organs. When the patient is capable of being reasoned with, 
the physician should enjoin the necessity of lying upon the side and of rising 
once or twice in the course of the night and emptying the bladder, or the object 
may be obtained by similar instructions given to the nurse or to the parent; 
as the concentrated quality of the nocturnal urine tends to produce such an 
impression on the mucous lining of the bladder as will be likely to cause its 
expulsion. The practice of attempting the cure of urinary incontinence by 
intimidation, and sometimes by brutal chastisement, is, even at the present 
time, not uncommon. That there is an exceptional case now and then to be 
met with of a boy utterly indifferent to all feelings of self-respect and of per- 
sonal cleanliness, who will yield to the promptings of nature's calls without 
reference to place, time, or circumstances, cannot be denied, and then the 
judicious enforcement of the Solomonic injunction will wonderfully conduce to 
a cure; but these cases are so rare that, as in the matter of capital punishment, 
where it is better that ten guilty persons should escape than that one inno- 
cent man should suffer, rather than subject a single child, whose infirmity 
is real, to such barbarism, it is better to allow many, whose incontinence 
is unreal, to escape what they deserve. 
In obstinate cases of urinary incontinence, after other remedies have 
failed to afford relief, the prostatic urethra and the neck of the bladder 
may be lightly cauterized with the nitrate of silver. For this purpose a 
solution of eight grains of the salt to one ounce of distilled water should 
be accurately applied by a catheter canula containing a stylet around the 
extremity of which is wrapped a dossil of cotton, which, after being satu- 
rated with the solution, can be protruded from the canula when the latter 
has been passed along the urethra to the portion of the canal to be caute- 
rized. In incurable cases of incontinence in the male, it will be necessary, 
for the comfort of the patient and to make his presence tolerable to those 
about him, that he should wear a urinal. 
The morbid growths which are met with in the bladder are both benign 
and malignant. 
Tumors of the Bladder. 
Fibroma.-Tumors of this class are the most common. The histological 
elements of fibromata are not alike. They are sometimes truncated or 
boss-like in form, arising from the inferior wall of the bladder with a sessile 
attachment, and when examined are found to consist of a dense, compact 
interlacing of connective-tissue fibres. 
An eminent citizen of Philadelphia whom I attended for two years, and who 
had previously had a stone crushed in London, died from what was supposed 
to be cystitis. An examination of the bladder after death revealed the pres- 
ence of a dense fibroma, about the size of a walnut, which had developed 
in the lower wall of the organ. In addition to the ordinary symptoms of TUMORS OF THE BLADDER. 
547 
catarrhal cystitis, extreme pain and spasm of the viscus were permanent 
attendants of the disease. 
Villous Fibroma, or Papilloma, is frequently met with in the bladder under 
different forms as to external configuration, sometimes presenting a dendritic, 
complex arrangement of branches or branchlets resembling a tree, at other 
times in the shape of truncated elevations with a raspberry-like surface, 
again as wart-like eminences, resembling miniature stems of coral, and finally 
as pedunculated, gelatinous outgrowths, bristling with hair-like papillae or 
villi. 
In all these different varieties the histological elements are the same, formed 
of a series of branching papillae or villi, more or less complex, which consist 
of an extremely delicate prolongation of the normal connective tissue of the 
bladder, inclosing one or more capillary loops, and surmounted with round, 
columnar, or many-sided epithelia. 
Papillomata may be single or multiple, and are often scattered over a con- 
siderable portion of the mucous sur- 
face of the bladder (Fig. 1318.) They 
are more common in women than in 
men, and are frequently met with in 
children. When the fibrous element 
prevails, they seldom bleed. Some- 
times they grow until the bladder is 
almost filled with their soft branches. 
I removed in one instance a growth 
of this nature from the bladder of a 
lady, springing from one side of the 
organ, and which, so far as I was able 
to judge from an exploration of the 
organ with the finger, occupied more 
than one-half of the viscus. The 
rapid growth of these neoplasms, and 
their soft and vascular nature, occa- 
sion not only great vesical irritation 
and urinary obstruction, together with 
incessant and painful micturition, but 
often also slight bleeding. The urine 
is frequently mixed with mucus, and sometimes with detached fragments of 
the growth. 
It is quite possible to mistake such a tumor for stone in the bladder. In 
a female patient under the care of Dr. Bodine, who presented not only the 
rational signs of calculus, but also the decisive physical sign yielded by the 
sound, I found, on dilating the urethra and introducing my finger into the 
bladder, a hard body the size of a small orange and having an irregular sur- 
face. It was moored by a narrow base to the side of the organ. Under 
pressure it broke down, and proved to be a papilloma, which had been com- 
pletely incrusted with the lime salts of the urine. These growths invariably 
return when removed, and may be regarded as incurable. 
Fig. 1318. 
Multiple papilloma of the bladder. 
Polypoid Fibroma, the rarest of all papillary growths in the bladder, 
when present is generally pedunculated, and consists of a basement layer of 
fine, loosely intersecting filaments of connective tissue, covered with vesical 
epithelium and supplied very sparsely with blood-vessels. It occurs with 
nearly equal frequency in males and in females. The symptoms which in- 
dicate the existence of vesical polypi are frequent urination and sometimes 
sudden retention, in consequence of the growth (when the pedicle is long) 
floating into the neck of the bladder, or even into the urethra. In a sin- 
gular case of this nature which I saw, the lady had suffered from great 
irritability of the bladder for seventeen years, and had been under the care, 548 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
at different times, of a number of the most eminent medical men in Philadel- 
phia, without obtaining relief. She was at one time lithotomized, under the 
impression that a stone was concealed in the bladder. Frequently during the 
years of suffering the urethra and bladder had been explored with care, but 
without offering any clue to the disease, until finally all hope of obtaining 
relief was abandoned. This lady, finally, was seized with partial retention, 
and sent for a physician in the southern part of the city, who, on making 
examination, discovered a small, soft, gelatinoid body like a pea lodged in 
the urethra, and attached to the interior of the bladder by a long, thread-like 
pedicle. The polypus was extracted, and with its removal disappeared all 
the vesical distress of the patient. 
Papillary Adenoma differs from the other varieties of fibrous vesical growths 
in having glandules imbedded in a stroma of connective tissue. It usually 
rises from the mucous surface of the bladder as a convex eminence with a 
broad base. In addition to the symptoms of vesical irritation and obstruc- 
tion which characterize the existence of this papillary growth in the 
bladder, valuable information may be acquired by hypogastric palpation and 
the use of the sound in the male, and by the finger in the female, which 
can be readily introduced into the viscus after the rapid dilatation of the 
urethra. 
Carcinoma of the Bladder, though rarely occurring as a primary affection, 
is frequently a secondary deposit when the disease exists elsewhere, or it 
may be propagated to the bladder by continuity of structure, when the 
vagina, the uterus, the rectum, or the prostate body is the seat of a malig- 
nant growth. 
The form under which it appears is that of epithelial cancer, and chiefly 
in the male, of mature or advanced life. Affecting as it almost invariably 
does the neck and the lower wall of the bladder contiguous to the neck, the 
disease, when primary, is believed to originate in the epithelium of the glan- 
dular portion of the prostate body. 
Epithelioma varies much in its behavior, sometimes concentrating its rav- 
ages on a limited portion of the bladder, sending into its cavity a large mass 
of alveolated connective tissue, infiltrated with disorderly arranged epithelia, 
and giving to the growth an induration readily mistaken for scirrhus. Or 
instead of one there may be several tuber-like projections. These growths 
after a time ulcerate, presenting the same ragged appearance and covered 
with the same foul discharge which characterize the cutaneous form of the 
disease. In other instances the tendency of the affection is to become dif- 
fused, infiltrating not simply the mucous and submucous tissues, but all the 
layers of the bladder, and extending to the ureter, seminal vesicles, and con- 
tiguous parts. One of the earliest signs of malignant disease of the bladder 
is hemorrhage. The pain extends to the lumbar and sacral regions and to 
the perineum, and is often lancinating in its character; the symptoms of 
vesical irritation, obstruction, and dysuria are also present. 
The progress of epithelioma is generally rapid, during which the bladder 
is likely to become opened by ulceration, permitting the escape of urine, 
and followed by all the evils of pelvic extravasation, among which the most 
common is peritonitis. Few patients survive more than from twelve to 
eighteen months. In one case which I saw with Professor Da Costa, there 
was reason to believe the disease had existed for five years; in a second, 
which was under the care of Drs. Stotler and Newcomet, the individual sur- 
vived three years ; and in a third case, which I saw in connection with Dr. 
Samuel Murphy, the patient lived about the same length of time. There are 
several recorded examples of the disease in which the fatal termination was 
postponed for a much longer time. 
Diagnosis.-As the signs which accompany epithelioma of the bladder 
belong to other growths of this viscus, there must always remain some un- SARCOMA OF THE BLADDER. 
549 
certainty in the diagnosis, unless determined by the sense of touch by an ex- 
ploration made through the rectum or the vagina, or when it is secondary to 
a like disease in the walls of one or the other of these cavities. Occasionally 
it is possible to discover through the walls of the abdomen an enlargement 
of the glands. Generally, however, the suffering in epithelioma, where 
ulceration exists, is exceptionally severe and the vesical tenesmus exceed- 
ingly distressing. Blood is also present in the urine in a large majority of 
cases, and after a time emaciation, loss of strength, and a sallow complexion 
reveal the peculiar cachexia of malignant disease. Should any fragments 
of the growth become detached by the contraction of the bladder and be 
discharged, the microscope can be called to our aid for the solution of the 
diagnostic problem. 
Sarcoma of the Bladder.-Several growths taken from the bladder and the 
morbid anatomy of which answers to sarcoma have been described. There 
is little doubt that tumors of this nature find a habitat in this organ. Those 
described have belonged to the round-celled variety of the disease. 
Treatment of Tumors of the Bladder.-Though in many of these mor- 
bid growths of the bladder little can be done except to alleviate the urgency 
of the symptoms, in some cases the surgeon is able, by an operation, to eradi- 
cate the disease permanently. When the object is palliation, oui' remedies 
must be addressed to relief of pain and vesical tenesmus; and suppositories 
of opium and belladonna or hyoscyamus wdll afford the greatest relief. When 
hemorrhage exists, the discharge of blood must be controlled by exhibiting 
such articles as gallic acid, turpentine, aromatic sulphuric acid, fluid extract 
of ergot, the pernitrate of iron, alum, etc. The application of ice-bags to the 
perineum and above the pubes, and injections of cold water into the rectum 
or the vagina, or sometimes into the bladder, will prove powerful adjuvants 
in arresting the bleeding. In addition to these measures, rest in the recum- 
bent position is of the first importance, taking care to keep the bowels regular 
and to avoid stimulants, to use a light, easily-digested diet, and to abstain 
from all sexual indulgence. 
Medicated or astringent injections thrown into the bladder, should the 
hemorrhage prove obstinate, may be tried, using for this purpose a warm 
solution of alum, five grains to the ounce of water, or one of Monsel's solu- 
tion of iron, eight to twelve drops of the iron to one ounce of water. When 
the case is one of fibroma having a pedun- 
culated attachment, there can be no doubt 
of the propriety of operative interference. 
In the female there is no difficulty in gain- 
ing access to the growth by a rapid dilata- 
tion of the urethra. For this purpose I 
employ an instrument with three blades 
(Fig. 1319), which is introduced, closed, into 
the canal (the patient being etherized), and 
afterwards expanded to the required degree. 
After removing the dilator, the finger is 
next passed into the bladder and the tumor located, when, with a long for- 
ceps (Fig. 1320) conducted over the finger to the growth, the latter can be 
grasped and extracted entire or by installments through the urethra. 
When the base of the tumor is broad and will not admit of being twisted 
away with the forceps, the wire ecraseur can be used with the greatest ad- 
vantage. Civiale employed for this purpose the lithotrite; the growth, being 
crushed with the instrument, was allowed to come away in fragments along 
with the urine, or was subsequently extracted. The operation is a hazardous 
one for the bladder, and should not be performed. 
In males, when the extraction of a tumor is deemed feasible and proper, 
in consequence of the length of the urinary canal rendering it practically 
impossible to use the proper instruments by this route, the bladder should 
Fig. 1319. 
Instrument for dilating the female urethra. 550 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
be opened either through the perineum, or, in very large growths, above the 
pubes. In this way Billroth successfully extirpated a large tumor from the 
FlG. 1320. 
Forceps for removing fibroma from the female bladder. 
bladder. Of 16 operations performed for the removal of papillary and sar- 
comatous tumors from the bladder, tabulated by S. W. Gross,* 6 died and 10 
recovered. Four of the patients were males and 12 females; 2 of the fatal 
cases were in males and 4 in females. Two cases of my own, both of which 
recovered, give us a total record of 18 operations, with 12 recoveries. The 
detachment of the growths was by evulsion, ligation, or scraping. 
Tubercle.-Tubercular disease of the bladder, though by no means common, 
does occasionally occur, but always accompanied by similar disease in other 
parts more or less closely related to the bladder, as the prostate body, the 
vesiculse seminales, the ureter, and especially the kidneys; the ovaries, 
rectum, and lungs suffer also. Females are less frequently affected than males, 
and adults are more obnoxious to the disease than either the young or the 
old. The deposit is found in the mucous and submucous cellular tissue, 
appearing in small, round, cheesy masses, which frequently coalesce, and 
eventually soften, forming ragged ulcerations. The tuberculous infiltration 
progressing, the ulcers often open into one another, causing extensive de- 
struction of the lining membrane of the bladder. 
The symptoms are by no means characteristic, differing very little from 
those common to morbid growths in the bladder, namely, frequent and 
painful micturition, and muco-purulent, purulent, or bloody urine. The 
treatment consists in rest in the recumbent position, anodyne suppositories 
to diminish the vesical irritation, and tonics, with nutritious articles of diet 
to sustain the general strength. The severe suffering caused by the urine 
acting on the ulcerations within the bladder, and the violent tenesmus and 
spasms of the organ which result, will be materially alleviated by opening 
the bladder through the perineum in the male, ami through the vagina in 
the female, and allowing the urine to escape as rapidly as it enters the viscus. 
In women, if this operation is declined, some relief will bo secured from a 
forcible dilatation of the urethra and the neck of the bladder to a degree 
that will for a time paralyze the sphincter vesicas muscle. 
The introduction of a catheter into the bladder in a normal condition of 
the urethra is a very simple and easy operation. I have been many times 
puzzled to comprehend in what consists the difficulty, and sometimes the 
mortifying failure, which physicians of many years of service in professional 
work frequently experience when attempting the task. 
I have traveled sixty miles to relieve a case of urinary retention, which 
the local medical attendant had failed, after repeated attempts, to catheterize, 
where the instrument passed into the bladder as easily as one would walk 
down a broad highway of the city. It is no unjust reflection on the medical 
profession to say that catheterization is the worst-done operation in surgery; 
Catheterism. 
* Gross on the Urinary Organs, third edition, p. 153. CATHETERISM. 
551 
and it is no exaggeration to assert that, considering the frequent necessity 
for the operation, and the lamentable consequences attending the maladroit 
use of the instrument, none is more important. I think the inaptitude 
may be traced, first, to a misapprehension in regard to the course of the 
urethra, which is supposed to be one with a number of curves; and, secondly, 
to a notion that considerable force is necessary to carry the catheter for- 
ward into the bladder; both of which impressions are erroneous. The urethra, 
when the penis is held in the proper position, has only a single curve, and 
that a very gradual one, the concavity being above (Fig. 1321), and the force 
which should be applied to the catheter in conducting it into the bladder is 
very slight indeed. 
While the operation is suffi- 
ciently simple in a natural con- 
dition of the urethra, it is very 
different when there are obstruc- 
tions in the course of the canal. 
It then becomes one of the most 
delicate procedures in surgery, and 
often requires for its successful 
execution exceptional anatomical 
knowledge, patience, manual tact, 
and skill. 
Fig. 1321. 
Catheters.-There are two kinds 
of catheters in use,-the hard and 
the soft; the former inflexible, 
and constructed of metal, the other 
flexible, made by applying to cyl- 
inders of linen or silk a solution of caoutchouc. 
The metallic catheter should be made preferably of silver. It should be 
perfectly smooth, curved at its vesical extremity, seven millimetres in di- 
ameter and ten or eleven inches in length. The beak of the instrument, 
which must be nicely rounded off, should have on each side a countersunk 
oval orifice or eye, the margins of which should be perfectly smooth and 
round. 
The other extremity, or handle, of the catheter should be furnished with 
two rings, by which the instrument, when necessary, can be tied in the blad- 
der, and which indicate the exact position of the catheter when the vesical 
extremity is in the urethra. 
The curve at the vesical extremity should not exceed, it is said, one-third 
the circumference of a circle whose diameter is three inches and a half. 
(Fig. 1322.) A trifling deviation from this, however, will not impair the 
usefulness of the instrument. 
Course of the urethra, and the relation of the bladder to 
the rectum; also the triangular ligament attached above to 
the arch of the pubes (a), and below embracing the mem- 
branous urethra (b); c, the bulbous portion of the corpus 
spongiosum. 
Fig. 1322. 
Metallic catheter. 
The elastic or gum catheter, which is soft and flexible, is worthy of high 
commendation. There is very little skill required for its introduction, and, 
when used without a stylet, it is incapable of inflicting any injury upon the 
urethra. Its use may even be intrusted to the patient himself, or to his at- 
tendant. These catheters are manufactured in France, England, and recently 552 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
in America. I can discover very little difference in their quality. There are 
three varieties in use, all exceedingly useful. One is quite firm, and admits 
of being curved into a definite shape by being placed first in warm and after- 
wards in cold water; it will retain with considerable pertinacity the curve 
thus given to it. This instrument is often stiffened by the introduction of a 
stylet. (Fig. 1323.) A second is perfectly flexible, except at its vesical ex- 
Fig. 1323. 
Soft catheter with stylet. 
tremity, which is firm and bent for half an inch, forming an elbow (Mercier 
catheter); and the third is a soft tube, as flexible as whip cord. (Fig. 1324.) 
The gum catheter is frequently constructed with 
an olive-shaped vesical extremity, which facili- 
tates the introduction of the instrument. (Fig. 
1325.) 
These instruments, however, all deteriorate 
by use, becoming rough and brittle when ex- 
posed long to the action of the urine. On this 
account they should always be carefully ex- 
amined after being used, in order to see if any 
damage has been sustained. I have seen very 
unpleasant complications follow neglect on this 
point, the end of the catheter breaking off and 
remaining in the bladder or the urethra. Great 
cleanliness should be observed in the employment of catheters, as it is 
more than probable that disease may be communicated by carelessness 
Fig. 1324. 
Soft catheter, curled, to show its flexi- 
bility. 
Fig. 1325. 
Olive-shaped gum catheter. 
in this respect. The instrument, after being used, should be thoroughly- 
cleansed by passing through its canal a stream of water and afterwards rub- 
bing its surface dry with a towel or soft piece of flannel. Nothing more ef- 
fectually prevents the metal from becoming tarnished by exposure to the 
air, or preserves the exterior of a gum catheter in a smooth condition, than 
the application of a little cosmoline before laying the instrument aside. 
Introduction.-The catheter may be introduced in any position of the pa- 
tient, sitting, standing, or lying on the back (though the last is generally to 
be preferred), with the shoulders a little elevated and the thighs drawn up 
and moderately separated. Standing on whichever side may be most con- 
venient, after rolling back the shirt of the patient, the surgeon, taking the 
glans penis between the thumb and index and middle fingers, turns the organ 
upward towards the abdomen, so as to convert the angle formed at the at- 
tachment of the penis to the pubes into a curve. The catheter, held in the 
other hand, with its concavity upward, and previously well oiled with sweet 
oil, is now introduced into the orifice of the urethra and immediately placed 
directly opposite to the median line of the body, when it is to be passed down- 
ward with a light hand. (Fig. 1326.) The penis at the same time (in order to CATHETERISM. 
553 
keep the urethra stretched) is pushed gently forward on the instrument until 
the end of the spongy portion of the urethra is reached, when, the handle of 
the catheter being depressed 
with a gradual sweep between 
the thighs of the patient, the 
point of the instrument passes 
through the membranous and 
the prostatic urethra into the 
bladder. There is not the 
least necessity for giving the 
patient any pain, the whole 
process, from beginning to 
end, occupying only a few 
moments. 
In what, then, consists the 
difficulty likely to be experi- 
enced by an unpracticed hand 
in introducing a catheter? 
The point of a small instru- 
ment may become caught in 
the lacuna magna or in the 
orifice of a urethral follicle. 
In consequence of the incor- 
rect description of the urethra 
by some anatomists, another error is frequently made. A bulbous part of 
the urethra is often spoken of, though none such exists. The bulbous ex- 
tremity of the corpus spongiosum is not traversed at all by the urethra, 
which leaves the spongy body just at the commencement of the bulb. If this 
is not understood, the handle of the instrument is not depressed sufficiently 
soon, and if impelled forward the point is liable to be thrust through the lower 
wall of the urethra. A third mistake is often committed when the point of 
the catheter reaches the commencement of the membranous urethra. If the 
handle of the instrument is then depressed too suddenly, its beak is arrested 
against the front part of the triangular ligament, and if urged onward may 
penetrate the upper w'all of the urethra. Sometimes, even after passing this 
point, if the handle of the catheter is too forcibly depressed, it is possible to 
perforate the upper wall of the canal behind the triangular ligament, when 
the instrument enters the pelvis behind the pubes. These are not imaginary 
accidents. I have seen them occur; and I have no doubt they have been 
frequently witnessed by other surgeons. Accordingly, when the cathetei' in 
being introduced meets with the least obstruction, instead of applying addi- 
tional force, it should be withdrawn for a little distance, the point slightly 
changed in its direction by elevating or depressing the handle of the instru- 
ment, and another attempt made to pass it onward. It is seldom that 
these manoeuvres require to be repeated more than once or twice before suc- 
cess is attained and the bladder is safely reached. The merest tyro can, in a 
healthy urethra, reach the membranous part of the canal; and if any diffi- 
culty is encountered between this part and the bladder which is not readily 
overcome by the instructions already detailed, he has a safe guide in the 
index finger, which, being introduced into the rectum, will serve to pilot the 
instrument safely through the remaining portion of the canal. 
Occasionally the meatus is preternaturally contracted and refuses admis- 
sion to the beak of the catheter. The same difficulty may be encountered 
when there exists a tight phimosis. In either case the proper course (if 
dilatation cannot be readily effected) is to enlarge the opening by incision. 
As the catheter enters the bladder, a finger should be slipped over its exter- 
nal orifice, so as to prevent the escape of the urine before the vessel for its 
reception is properly placed. It will often be found convenient to turn the 
patient on the side while the urine is being discharged, in which position a 
Fig. 1326. 
Introduction of the catheter. 554 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
chamber or cuspidore can be advantageously used for its collection. Aftei 
the last drops have escaped, a finger should again be placed on the end oi 
the catheter as it is withdrawn, so that the small amount of fluid which the 
instrument contains shall not be allowed to escape until its beak has been 
placed over the urinal. 
When it is deemed proper to catheterize in the standing posture, the patient 
should plant his buttocks against a wall or bed-post, at the same time in- 
clining the body somewhat forward, in order to relax the abdominal muscles. 
The thighs must also be abducted and slightly flexed, and the feet turned out- 
ward. If the patient occupies the sitting position, the nates should rest on the 
front of the chair-seat, with the limbs wfidely separated. In both the sitting 
and the standing posture the surgeon takes his seat directly in front of the 
patient. The remaining steps of the operation are the same as when the 
instrument is inserted in the recumbent position. 
Some surgeons, fond of investing even the simplest operations with a cer- 
tain air of display or dramatic effect, introduce the catheter with its con- 
vexity upward, and, when the penile portion of the urethra is passed, suddenly 
impart to the instrument a graceful twirl, by which the curves are reversed, 
and the handle, after describing a semicircle, sinks down between the thighs. 
This is the tour de maitre of the French. I doubt very much the propriety 
of making a brother man a stage on which to enact a surgical flourish. 
In introducing the flexible gum catheter, one which bears no stylet, the 
manipulation is altogether different from that required by the metal instru- 
ment. After oiling its surface, the catheter is grasped near its vesical ex- 
tremity, which, being inserted into the orifice of the urethra, is pushed onwrnrd 
by short impulses, the instrument never being caught for this purpose at a 
greater distance than one inch from the meatus. 
Every practitioner should have in his possession a number of both metal 
and gum catheters of assorted sizes. For the purpose of the ordinary prac- 
titioner it is entirely unnecessary to purchase the whole series belonging to 
the different scales, which range from twelve to thirty. Half a dozen of each 
will meet every requirement. 
Retention.-There are circumstances which render it desirable to retain a 
catheter for some time in the bladder. Foi' this purpose it becomes necessary 
to secure the instrument by such checks as will prevent its being expelled. 
A number of contrivances have been devised to accomplish this end. A very 
simple plan is to pass narrow strips of adhesive or porous plaster through 
the rings of the catheter, and apply their free ends to the body of the penis. 
(Fig. 1327.) 
Another and very satisfactory method is to apply first a T-bandage to the 
body, and then fasten the catheter in place by long pieces of tape passed 
through the rings of the instrument and their ends attached to the perineal 
strips of the bandage; or an elastic band may be secured to the catheter and 
made to buckle around the penis. 
Mr. Holt has devised what is called a winged catheter. (Fig. 1328.) The 
Fig. 1327. 
Fig. 1328. 
Catheter retained by adhesive plaster. 
Holt's winged catheter. 
irritation caused by the lateral branches is such that it is not probable this 
instrument will meet with much favor. 
Whenever it is deemed necessary to secure a catheter in the bladder, its CATHETERIZATION IN THE FEMALE. 
555 
beak must be placed just within the neck of the viscus. If introduced too 
far, in the event of erection taking place the point of the instrument may 
damage the inner surface of the bladder. Barely is any inconvenience ex- 
perienced from the passage of the catheter. Urethral fever, which is so com- 
monly seen after the use of bougies, is not often witnessed after catheteriza- 
tion. In the female it is exceedingly infrequent. Occasionally in persons of 
an unusually irritable organization a peculiar, sickening sensation is felt, 
however delicately the instrument may be managed, which may induce* an 
attack of syncope. I have known a strong man to faint away during this 
operation, although there wTas no evidence that any pain was experienced. 
A knowledge of this fact renders it necessary to be cautious when cathe- 
terism is practiced in the standing or sitting position. In the case referred 
to, the patient was in the erect posture, and fell with considerable force upon 
the floor, where he lay some time before the effects of the shock passed over. 
The portion of the urethra most likely to excite such eccentric phenomena 
when touched by the instrument is the prostatic. 
Catheterization in the Female.-The conditions which produce retention 
in the female are multiform, and may be described as mechanical, spasmodic, 
traumatic, paralytic, psychical, and postural. 
1st. Mechanical.-The mechanical include all causes which, by obstructing 
the vesical orifice of the bladder, or by compressing its walls, prevent the flow 
of urine. Thus, a calculus may be washed by the stream of urine into the 
neck of the bladder and obstruct its canal. A foreign body is sometimes 
pushed into the same position from without, and, like the stone, acts as a 
stopper to the mouth of the viscus. A polypus having a long pedicle may 
do the same. Obstructive pressure may also be exerted by uterine displace- 
ments, by the gravid uterus, and by ovarian and other pelvic tumors. 
2d. Spasmodic.-Spasmodic retention may be produced by any irritant 
acting on the sphincter muscle of the bladder, such as cold, the absorption of 
cantharides, hemorrhoids, fissure of the rectum, and abscess of the labia. 
3d. Traumatic retention is likely to be caused by contusions of the perineum 
or of the vulva, by pressure of the foetal head in a tardy passage through 
the inferior strait of the pelvis, and by the blades of the forceps in instru- 
mental delivery. 
4th. Paralysis oi the bladder resulting in retention is often the consequence 
of cerebral or spinal concussion or compression, fracture of the vertebrae, and 
over-distention of the organ. 
5th. Psychical.-Under this head are included all those instances of reten- 
tion in which, from hysterical or emotional causes, the patient is unable, 
voluntarily, to empty the bladder. 
6th. Postural.-Notwithstanding there may be neither organic nor func- 
tional disorders of the bladder, females are sometimes unable to discharge the 
urine in consequence of being compelled to maintain the horizontal position. 
Catheterization in the female is to the young practitioner often a very 
embarrassing operation, as it is proper that the patient shall be subjected 
to no unnecessary personal exposure. 
The female catheter should be metal, six inches in length, eighteen or 
twenty millimetres in circumference, perfectly smooth, and perforated with 
Fig. 1329. 
Female catheter. 
a number of minute holes near its vesical end (Fig. 1329), which should 
be well rounded and slightly curved. These openings must not be too large, 
otherwise the mucous membrane of the bladder oi' of the urethra is liable 556 
INJURIES AND DISEASES OF THE GENITO-URINARF ORGANS. 
to slip through the perforations and become strangulated, causing great 
pain in the removal of the instrument, and even wounding the prolapsed 
membrane. 
The most convenient plan of introducing the catheter is for the practi- 
tioner, after having first brought the woman close to the edge of the bed, 
with the limbs drawn up, to take his seat alongside, with his face towards 
that of the patient. Passing the right 01* the left hand, according to the side 
of the bed from which one operates, un- 
der the bedclothing and beneath the 
thigh of the patient, the top of the in- 
dex finger, with its palmar surface up- 
ward, is placed against the commence- 
ment of the upper wall of the vagina, 
immediately above which can be felt the 
little eminence which marks the orifice 
of the urethra. With the other hand 
the catheter is carried under the cloth- 
ing in front of the thigh, and its point 
(concavity upward) conducted along 
the guiding finger into the canal, and 
onward into the bladder. (Fig. 1330.) 
Just before the tube enters the latter a 
finger should be placed on its extremity, 
so as to control the orifice until a cup, cuspidore, or some other convenient 
vessel is placed in position to receive the urine. When the bladder has been 
emptied, the finger should again be applied to the end of the catheter, by 
which means the urine that remains in the instrument will be prevented from 
spurting out through its eyes until it is placed over the urinal. 
When the physician is inexperienced in the use of the catheter, or when 
his sense of touch is not sufficiently delicate readily to identify the anatomical 
peculiarities of the parts, I have no hesitation in advising such an exposure 
as will enable him to perform the operation under the inspection of the eye. 
Though this is in direct opposition to obstetric teachings, I am quite sure 
that any lady would be less annoyed, in view of the promptness with which 
the instrument can be used under these circumstances, than by the delay 
and blundering manipulation to which she is sometimes subjected when the 
prescribed order of procedure is followed. 
To insert the catheter directed by the eye, the woman may be placed across 
the bed, on her side, her hips near its edge, with the limbs drawn well up 
towards the body; the clothing being raised so as to expose the nates, and the 
labia separated, the instrument can be introduced without the slightest diffi- 
culty. The operation may also be done with the patient on the back and 
the limbs drawn up and separated. The bedclothing can be raised and tucked 
in round the limbs and along the sides of the perineum, so that nothing but 
the vulva shall be exposed, when the introduction of the catheter will be the 
work of a few moments. 
Complications in the use of the catheter.-A prolapse of the mucous membrane 
of the bladder or of the urethra through the perforations in the catheter 
when these openings are too large has already been mentioned. When such 
an accident occurs (which may be known by the resistance encountered when 
an attempt is made to withdraw the tube), the surgeon should endeavor, by 
pushing the instrument farther inward, and by gentle rotation, to disengage 
the incarcerated folds. Failing in this, there should be thrown through the 
cavity of the catheter a quantity of sweet oil, the presence of which will 
generally facilitate the withdrawal of the tube. 
Prolapse of the bladder will produce such a sharp angle at the neck of the 
organ that, when the viscus becomes distended with urine so that it cannot 
be replaced, the silver catheter cannot be made safely to pass the bend. In 
a complication of this kind a soft, flexible, gum instrument must be used. 
Fig. 1330. 
Position in introducing female catheter. AFFECTIONS OF THE SPERMATIC CORD. 
557 
The urethra and the neck of the bladder may be so long compressed by the 
foetal head in a tedious labor that catheterization becomes necessary. Under 
these circumstances, the obstruction to the use of the tube can best be over- 
come by pushing up the presenting part of the child before inserting the 
instrument. 
Affections of the Spermatic Cord. 
The affections to which the spermatic cord is liable are wounds, contusions, 
inflammations, hydrocele, hsematocele, and varicocele. 
Wounds inflicted over the pubes, or on the abdominal walls above the line 
of Poupart's ligament, and kicks or blows applied over the same region, 
necessarily expose the cord to injury. If the spermatic artery is cut or torn, 
the hemorrhage will be free, and will require the ligature. 
Rwptfure of the vas deferens is said to occur occasionally from falls, forcible 
abduction of the limbs, etc. The signs which have been described as accom- 
panying the accident are deep-seated pain in the inguinal canal, following a 
feeling of something having given W'ay in the groin, swelling of the testicle, 
and a discharge of arterial blood from the urethra. 
Mr. Hilton mentions three cases of this injury, which have been published 
by Holmes. As the blood which was discharged from the urethra was proven 
not to have come from the bladder, the catheter, when passed into this 
viscus, evacuating only clear urine, it was inferred that its true source was 
the deferential artery, and that it had passed along the vas deferens to the 
common ejaculatory duct and by this route reached the prostatic part of the 
urethra. In all of Mr. Hilton's cases the accident was followed by wasting 
of the testicle. As this injury has never been verified by dissection, and as 
it is difficult to conceive how the duct could have been seriously affected by 
the causes which are assigned for its rupture, the reality of the accident may 
be questioned. 
If the vas deferens should be severed, even though its ends were apposed 
and retained by the introduction of fine silk sutures through the investing 
cellular tissue, there would be little probability of again establishing the con- 
tinuity of the seminal channels; though, if the wound was an open one and 
the cord exposed, the attempt might be made. 
When the entire cord is divided, after securing the spermatic artery and 
stitching the ends of the vas deferens, the other constituents should be brought 
together by a few interrupted sutures. If the external opening is not large 
enough to admit of a free access to the cord, it must be enlarged. During 
the late American war there were five cases of wounds of the spermatic cord, 
in three of which the spermatic artery was tied. The cord was completely 
severed in three of the five cases. Ligature of the spermatic artery is a 
very rare operation. It has been done by Professor Hecker, by Beck, and 
by Malgaigne. 
Atrophy of the testicle has been observed to follow these wounds of the 
cord, and in one of the cases reported during the late war the patient was 
left impotent. 
Inflammation of the spermatic cord is rare as a primary affection. It may 
succeed an attack of acute orchitis, epididymitis, or a suppressed urethritis. 
It is sometimes seen to accompany malignant diseases of the testes. 
The signs of the inflammation are swelling, induration, great tenderness, 
and a sense of dragging weight experienced in the course of the inguinal 
canal. The inflammation is sometimes accompanied by severe constitutional 
disturbance. Inflammation of the cord terminates in resolution, rarely in 
suppuration. 
Treatment.-When the inflammation is a sequence of a contiguous in- 
flammation (as of orchitis or epididymitis), the removal of the latter will 
be followed by the subsidence of the disease in the cord. If not, or if it 
supervenes on the reception of a contusion, it will be necessary to apply 
the remedies directly over the cord. 558 
INJURIES AND DISEASES OF THE GENITO-URINARF ORGANS. 
The hair being removed, a few leeches may be applied above the pubes, a 
lotion of lead-water and laudanum laid over the parts, and the testicle suf- 
ficiently wrell supported to relieve the cord of any drag or weight. Should 
the inflammation terminate in abscess,-a very rare occurrence,-the pus 
will require to be evacuated by an incision. 
Fatty tumors of the cord are quite common. There is a considerable 
amount of adipose tissue existing along the cord as a normal condition. 
It is sometimes massed in the connective tissue at a single point in the 
cord, either below or above the external abdominal ring, or it may consti- 
tute a long roll, with one or several constrictions. I have examined cases of 
fatty spermatic cord which had been confounded with hernia. The doughy 
feel of the growth might readily cause it to be mistaken for a mass of omen- 
tum. Its fixed position and the absence of impulse to the enlargement 
during coughing will be sufficient to correct any misapprehension on this 
point. 
In most instances these fatty growths are altogether harmless, and require 
no surgical treatment. When observed to increase gradually in size and when 
situated above the external ring, they may be atrophied by wearing a truss, 
the pad of which is placed directly over the growth. Only when the tumor 
becomes inconvenient or troublesome from its size will extirpation be neces- 
sary. In performing this, the greatest care must be taken not to wound the 
components of the cord. It is possible for the growth to be so completely 
interwoven with the different parts of the latter as to require the extirpation 
of cord and testicle. A case of this kind, demanding this radical procedure, 
was operated on by Mr. Lawrence. The tumor measured eight inches in 
length by six in breadth. A sarcoma subsequently appeared at the seat of 
the first excision. This is occasionally witnessed after thd removal of fatty 
tumors, and has led to the erroneous idea that such growths are recurrent. 
Operations were subsequently performed by Mr. Curling at different times 
for the removal of sarcomatous tumors from the original site of the first, the 
last being done at a period of twenty years from the primary operation. 
The man finally died, fifteen weeks after the last excision. 
Carcinoma of the spermatic cord is seldom witnessed. Curling records two 
cases, one of which came under the observation of Hunter, and the other 
was removed by Mr. Spence, of Edinburgh. There was no doubt entertained 
in either of these cases that the disease, which was of the medullary variety 
of cancer, commenced primarily in the cord. In the one described by Hunter, 
the omentum and lumbar glands were also affected. Little can be gained 
by an operation in such cases, as the disease must inevitably return. The 
operation of Mr. Spence was followed by death, sloughing and peritonitis 
setting in after the excision. 
Spasmodic retraction of the cord is a common effect of the passage of a 
stone, or of crystals of uric acid or of oxalate of lime, along the ureter. It 
may attend almost every irritation seated in the kidney, urethra, or sexual 
apparatus. It is sometimes seen in young persons possessed of an irritable 
nervous system. It is produced by the irritation being communicated to the 
cremaster muscle through the agency of branches of nerves distributed to 
the cord. The testicle during the spasm is drawn up towards the external 
abdominal ring. Twice have I seen in young lads the testes retracted into 
the canal. 
The treatment is either palliative or radical. When the spasm is attended 
with pain, a hot hip-bath or a fomentation of hot water to the parts will 
sec:ire its resolution. Should this fail, a hypodermic injection of morphia, 
or morphia and belladonna by the mouth, may be administered. 
Permanent relief can be obtained only by searching for the cause, and, as 
far as possible, removing it by appropriate treatment. When it is the result 
of general nervous irritability in young persons, a careful inquiry should be 
made into their private habits. In many of these cases iron and belladonna 
and camphor will exert a good effect. AFFECTIONS OF THE SPERMATIC CORD. 
559 
Syphilitic enlargement of the spermatic cord is occasionally seen among 
the later manifestations of this disease, though usually in connection with a 
similar state of the testicle. 
It must be treated by the use of those remedies which are employed for 
constitutional syphilis. 
Hydrocele of the spermatic cord may occur under three different forms,- 
diffused, encysted, and congenital, or what I prefer to call the abdomino- 
inguinal. 
This subject will be better understood if we recur for a moment to one or 
two anatomical and physiological facts. 
The testicle, in its descent from the lumbar region to the scrotum, carries 
with it a duplication or double layer of the peritoneum. There consequently 
exists a prolongation of this serous sac, from the internal abdominal ring to 
the bottom of the scrotum, one layer of which lies in contact with the cord 
and the tunica albuginea of the testicle, and the other with the inner sur- 
face of the cremaster muscle and the scrotum. There is, therefore, a space 
more or less complete between these two laminae. Ordinarily the two layers 
of this funicular process become blended into one, above the external ring, 
cutting off all communication between that part below containing the testicle, 
which remains open, and that part above, where it closely invests the cord. 
If, however, the two layers above become blended at the internal and ex- 
ternal rings, the intermediate portion remaining separate, and a collection of 
serum should take place, they form an oblong swelling, or a diffused hydrocele 
of the cord. 
Again, this tubular tunic of the cord may contract at one or more places 
in the course of the cord, the intermediate portions remaining unclosed, thus 
converting the membrane into a number of closed sacs; if, in this condition, 
a collection of serum should occupy one or 
more of these compartments, it will consti- 
tute an encysted hydrocele of the cord. 
Lastly, when the contraction of the two 
layers of the tubular process of peritoneum 
occurs round the cord only at or near the 
external ring, leaving the remaining portion 
above unclosed and, of course, communicating 
with the cavity of the peritoneum above, there 
exists a condition which, when this tubular 
canal becomes filled with serum, answers to 
what is designated as congenital hydrocele. 
As all of these forms of hydrocele belong 
chiefly to children, and are found in both 
sexes, it will only be necessary to substitute 
the round ligament in the female for the 
spermatic cord in the male in order to render 
them intelligible in the former sex. 
Fig. 1331. 
Diffused Hydrocele of the cord consists of 
a collection of serous fluid within the unob- 
literated portion of the tunica vaginalis of 
the cord, forming an elongated cylindrical or 
ovoidal swelling, which becomes somewhat 
pyriform in the erect position by the gravi- 
tation of the fluid. This swelling may extend 
from a short distance above the testicle to 
the internal ring (Fig. 1331), and is covered 
in by the cremaster, the transversalis fascia, 
the aponeurosis of the external oblique muscle, and the abdominal integu- 
ment. The accumulation may vary in size from the thickness of the little 
finger to the bulk of an egg. 
Diffused hydrocele of the cord. 560 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
The swelling is soft, compressible, and fluctuating, and when any portion 
which appears below the external ring is pressed upon by the finger, the 
contents will recede into the inguinal canal, to reappear on removal of the 
pressure. When the collection is large and the overlying layers of tissue are 
somewhat attenuated, translucency may be recognized by a proper use of the 
light test. The description which has been given of this form of hydrocele 
by Pott is, in my opinion, entirely at variance with both the anatomical and 
the physiological structure of the cord and its tunic, answering better for 
oedema than for hydrocele. 
Diagnosis.-Diffused hydrocele may be confounded with omental hernia, 
encysted hydrocele, and lipoma. The following distinguishing characteristics 
between this affection and omental hernia will aid in the diagnosis: 
DIFFUSED HYDROCELE. 
No impulse communicated to the swelling on 
coughing. 
Irreducible nature of the swelling by pressure. 
Gradual reappearance of the swelling after 
being diffused by pressure. 
Fluctuation on manipulation. 
OMENTAL HERNIA. 
Impulse communicated on coughing. 
Reducible by taxis, if of the reducible variety. 
Sudden and forcible descent of the omentum 
on coughing after reduction. 
Doughy feel on pressure. 
If the omental hernia should be irreducible, the obscurity will be very 
embarrassing, even to the most experienced surgeon, but may generally be 
cleared up by the exploring needle, which, in the case of hydrocele, would 
exhibit the characteristic fluid. Even with this sign a false conclusion might 
be reached, as the sac of an omental hernia may contain a similar fluid. 
Treatment.-Small collections of fluid require no interference. When, 
however, the accumulation is observed steadily to increase, its absorption 
may first be attempted by introducing a fine-bladed tenotome into the sac 
and scratching its interior at several points, following the scarification by 
the pressure of a truss, or by a compress and spica roller. Should this 
method fail, one or two fine silk threads may be deposited as a seton in the 
sac, and be allowed to remain thirty-six hours, pressure 
being made over the swelling after their removal. 
These threads can be made more effective by soaking 
them in the tincture of iodine previous to their intro- 
duction. 
Finally, as a last resort, the fluid may be drawn off by 
a fine trocar, and the tincture of iodine injected into the 
sac through the canula. 
Fig. 1332. 
Encysted Hydrocele of the cord appears as a circum- 
scribed swelling in the course of the cord, of an oval form, 
and rarely exceeding a walnut in size. It may occur 
below the external abdominal ring or witbin the in- 
guinal canal, and projects chiefly in front of the cord. 
There may be one or several of these cysts (Fig. 1332). 
They usually contain a straw-colored fluid, coagulable on 
the application of heat. Spermatozoa are said to have 
been found in this liquid, which could only occur by some 
communication between the cyst and the vas deferens, 
or with the epididymis below. 
Giraldis, of Paris, has described a structure in the 
spermatic cord of infants, consisting of vesicles and con- 
torted tubes, which he regards as the remains of the 
Wolffian body, and which he believes to be the source of 
the encysted hydrocele. 
Diagnosis.-The liability to mistake encysted hydrocele for hernia exists, 
as in the diffused form, especially when the serous collection is within the 
canal; yet by noticing the absence of impulse, gurgling, and resonance, and 
Encysted hydrocele of the 
cord. HEMATOCELE. 
561 
the constancy of the swelling, even in the recumbent position, with the im- 
possibility of forcing the tumor either into the abdomen or out through the 
external ring (peculiarities which belong to hydrocele), a reasonable degree 
of certainty may be obtained as to the nature of the disease. 
When an encysted hydrocele is below the external ring, the diagnosis is 
less difficult. The tumor will be well defined, have a uniform shape, be trans- 
lucent, and be free from impulse on coughing. 
Treatment.-Encysted hydrocele often requires no treatment whatever, 
as it will frequently disappear spontaneously. The parts over the swelling 
may be painted with Lugol's solution of iodine or with a strong solution of 
muriate of ammonia, or an ointment of iodoform may be rubbed into the 
tumor. The pressure of the pad of a truss will, as in the diffused form of the 
disease, often cause the absorption of the serum. When the swelling ex- 
hibits a tendency to increase, one or two threads, soaked in tincture of iodine, 
may be introduced into the sac, and allowed to remain for twenty-four or 
thirty-six hours; or twenty or thirty drops of tincture of iodine may be in- 
jected into the tumor, after draining off the fluid by the trocar and canula. 
Congenital Hydrocele of the spermatic cord is a rare affection. When it 
exists, the funicular process is closely adherent to the cord at the external 
ring, but remains open above, and communicates with the abdomen. 
It must not be supposed, however, that the communication with the abdo- 
men is always free; in other words, that the cord lies loose in its funicular 
tunic. If this were the case, a portion of the intestine or omentum would 
descend as readily as serum, and we should have hydrocele and hernia at 
the same time. This does occasionally occur, but it is not common. The 
investing prolongation of the peritoneum adheres sufficiently close in most 
instances to the cord to allow only of the accumulation of the fluid which 
constitutes the hydrocele. 
The symptoms of congenital hydrocele of the cord are a soft, fluctuating 
swelling in the canal, markedly increased when the patient stands erect, and 
diminished when he assumes the recumbent position. By pressure on the 
swelling, when the body is in the latter posture, the tumor can be made to 
disappear, the fluid being forced back into the cavity of the peritoneum, 
to reappear quite slowly when the patient gets upon his feet. Coughing also 
communicates an impulse to this variety of hydrocele. 
The alternate increase and diminution of the tumor, according as the 
standing or the horizontal position is assumed, and the presence of a slight 
impulse during forcible straining or coughing, cause this hydrocele strongly 
to resemble hernia. 
In hernia, however, the tumor recedes suddenly and completely upon taxis, 
its retrocession being often attended with a distinct, gurgling sound; and 
when it reappears under the suceussion imparted by coughing, it starts out 
suddenly into the canal. These characteristic signs are in striking contrast 
with the tardy disappearance and reappearance of congenital hydrocele under 
similar conditions. To these differences may be added the sign of trans- 
lucency always present in uncomplicated hydrocele, when the tumor is suf- 
ficiently large to allow the application of the light test. Any of the pre- 
ceding forms of hydrocele of the spermatic cord may be conjoined with a. 
hydrocele of the tunica vaginalis testis. 
Treatment.-The proper plan of treatment is to apply a truss, which, by 
compressing the sides of the canal together, favors the closure of the funic- 
ular process at the internal ring. 
Haematocele of the spermatic cord, like hydrocele, may be either diffused or 
encysted. 
Diffused hcematocele is produced by rupture of one of the spermatic veins, 
in consequence of external violence or during some unusual straining efforts. 
In one instance mentioned by Maunder the accident occurred during con- 
vol. ii.-36 562 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
nection. These veins being inclosed within the funicular sheath, the blood 
in case of their rupture extravasates into the connective tissue of the cord, 
passing upward and downward in the direction of the rings, and even 
descending as low as the testicle. 
The symptoms resemble those of hydrocele in the location of the swell- 
ing, but differ from the latter in that the blood tumor appears suddenly and 
generally after some extraordinary muscular effort or some external injury, 
and in the latter event is accompanied by discoloration or ecchymosis of the 
groin and scrotum. 
In one case, that of Mr. Freke, the swelling of a hsematocele was mistaken 
for hernia, and the parts were laid open. Mr. Bowman* mentions a case of 
hsematocele in which the tumor eventually extended to the knee (Fig. 1333), 
and which finally proved fatal by hemorrhage and 
by hectic fever consequent on destructive changes in 
the enlarged mass. 
Encysted hematocele of the spermatic cord is ex- 
ceedingly rare. I have never seen an instance of the 
disease. There is every reason to believe that when 
it does occur it is generally a complication of encysted 
hydrocele of the cord ; a spermatic vein having given 
way, so as to allow its blood to mingle with the 
serum of the sac, forming a mass of loose, dark clots 
or slightly stratified coagulations. These may re- 
main for a long time unchanged, becoming gradually 
absorbed, or they may cause sufficient irritation to 
produce suppuration. The tests for diagnosing hy- 
drocele of the cord from hernia may be applied in 
establishing a distinction between rupture and 
hsematocele, but between the latter and hydrocele 
the grooved needle alone can determine the dif- 
ference. 
Treatment.-Rest in the recumbent position and 
the local application of cold are the remedies indi- 
cated in a case of hsematocele. These may be sup- 
plemented, if not sufficient to control the hemorrhage, 
by a thick compress laid over the course of the in- 
guinal canal and firmly secured by a spica roller on 
the groin. In the event of extreme measures becoming necessary from the 
continuation of the bleeding, the cord should be uncovered by dividing the 
integuments and the aponeurosis of the external oblique muscle of the ab- 
domen, and tying the vessel or vessels at fault. There can scarcely ever be 
a necessity for castration in such a case, though this operation was done in 
one instance by Pott. 
Varicocele is a term used to designate a dilated, elongated, and tortuous 
condition of the spermatic and pampiniform veins of the cord. (Fig. 1334.) 
The condition is sometimes termed circocele. The disease is quite common 
in. early manhood, from fifteen to thirty-five years of age, and is rarely seen 
under puberty. 
From the absence of a valve in the left spermatic vein at the point of its 
entrance into the corresponding renal vein (a fact first pointed out by Dr. 
John B.rinton, of Philadelphia), varicocele almost invariably occurs on the 
left side.j* The same condition is seen in the veins of the left ovary of the 
female. 
To .this may be added, as having also some determining influence, the rec- 
tangular relation of the two veins, spermatic and emulgent, at their junction, 
the superincumbent position of the sigmoid flexure of the colon, and the 
Fig. 1333. 
Bowman's case of haematocele. 
® Curling, Medico-Chirurgical Transactions, vol. xxxiii. p. 233. 
f There, is great.irregularity in the presence and the position of the valves of the spermatic veins. VARICOCELE. 
563 
greater length of the left spermatic vein. Occasionally, however, varicocele 
is met with on the right side, and sometimes on both sides. 
Landouzy, in his work on varicocele, states 
that of 5639 army recruits rejected on account 
of that disease, 4881 were affected on the left side, 
344 on the right, and 414 on both sides. The 
frequency of double and of right-side varicocele 
mentioned by this author will, I think, strike any 
one as remarkable. Though I examined a large 
number of recruits during the late American war, 
I did not witness a single instance of right-sided 
varicocele. 
Marshall states that in 30,000 recruits examined 
by him, no case of well-marked varicocele was 
observed on the right side. Sir Astley Cooper 
never saw the disease on the right side; and of 
the 120 operations performed by Breschet for 
the cure of varicocele, only one was done on the 
right side. This disease is estimated by Hum- 
phry as occurring once in every ten males. 
Of 166,317 recruits inspected in the districts 
of Great Britain and Ireland during ten years 
ending March 31, 1853, 55,474 were rejected; of 
the latter number, 3911, or 70.5 per 1000, were 
rejected for varicocele.* Of 2,165,470 recruits 
examined in France in ten years, from 1850 to 
1860, 20,553, or 10.05 per 1000, were exempted 
for varicocele. A proportion considerably greater 
will be found to exist in the United States. 
Causes.-The great length of the spermatic 
veins, their tortuous course, the irregularity in 
the presence and position of their valves, the 
pressure likely to ensue from fecal accumulations 
in the sigmoid flexure of the bowel, any relaxed 
condition of the abdominal or cremaster muscles, 
all contribute to embarrass the circulation through 
these venous channels, and thus favor the pro- 
duction of the dilatation. I do not think that 
the disease can be often traced to family pecu- 
liarities, as it is rare to see more than a single case in the same family, 
and the coincidence of father and son being both subjects of varicocele is 
not common. 
In addition to these structural or determining causes there are a number 
of exciting ones, under which head may be included all that in any way 
tend to determine an unusual amount of blood to the testicles, as heavy lift- 
ing when the body is in a stooping position, straining efforts in defecation on 
account of constipation, excessive venereal indulgence, bareback riding, and 
a preternatural redundancy of the scrotum. 
The marching, fatigue, and exposure incident to the life of a soldier must 
exert a considerable influence in producing the disease, as we find that in the 
monthly reports of the sick and wounded during the late American war there 
are recorded 7270 cases of varicocele. 
Symptoms.-Varicocele may exist without causing any particular uneasi- 
ness, physical or mental. It is gradually developed, and generally, as it pro- 
gresses, there are experienced a sense of weight and a dull, aching pain 
extending along the cord and to the small of the back. As the veins increase 
in size they form a soft, doughy, convoluted, and elongated mass, not inaptly 
compared to a bunch of cords or of earth-worms, and extending from the 
Fig. 1334. 
Varicocele veins. 
* Curling on the Testes, p. 527. 564 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
lower part of the scrotum up towards the external abdominal ring. The 
scrotum, in consequence of the additional weight which it is compelled to 
sustain, becomes relaxed and elongated, the color of the blood in the veins 
being quite visible through its walls. 
In many persons the disease exerts a very depressing effect on the mind, 
fears being entertained that the virility of the parts will be damaged by the 
enlargement. 
The structural changes which occur in bad cases of varicocele affect both 
the spermatic veins and the testicles. The veins at some points are very 
much thickened by inflammatory infiltration of their walls, imparting a 
knotty appearance, w'hile at others their coats are markedly attenuated. 
Phlebolites are occasionally observed in the cavities of these vessels. The 
sluggishness of this circulation in the venous trunks necessarily deprives the 
testicles of that free interchange of blood which is essential to their proper 
nutrition ; consequently the testis of the affected side becomes soft, and fre- 
quently atrophies to a greater or less extent. 
Diagnosis.-The diseases with which varicocele is often confounded are 
scrotal hernia and congenital hydrocele. The points in which scrotal hernia 
and varicocele resemble each other are the following: both produce enlarge- 
ments in the scrotum; both commence above and descend; presuming the 
hernia to be reducible, both disappear in the recumbent and reappear in the 
erect position; and in both there is an impulse communicated to the hand on 
coughing. 
The feel of a mass of tortuous, convoluted veins is very unlike that ob- 
tained from the uniform surface of either an intestine or omentum. The 
crucial differential test, however, is both simple and decisive. Let the pa- 
tient take the horizontal position, wThen, upon compressing the scrotum, the 
swelling will disappear. Let a finger be now placed over the external ab- 
dominal ring and the patient be requested to rise to his feet. If the case 
is one of hernia there will be no return of the tumor; but if the disease is 
varicocele it will quickly reappear, as the finger, which, in the first case, 
occludes the only opening through which the rupture can escape, in the 
last case, by pressing the spermatic veins, prevents the blood from returning 
into the abdomen, and thus causes their trunks below to become distended. 
In view of so simple a test for establishing a correct diagnosis, it seems 
inexcusable in a physician to commit the blunder which is very common, of 
placing a truss on a patient with varicocele, under the impression that the 
swelling is due to hernia. 
In congenital hydrocele there are the same recedence of the swelling in the 
recumbent and the same reappearance in the erect position as characterize 
varicocele; but the translucency of the former, when tried by the test of 
light, is sufficient to remove any doubt as to the nature of the tumor. 
Treatment.--In many cases of varicocele, especially in persons of mature 
life, the disease remains stationary, or makes such slight progress as to 
demand little, if any, attention. When, however, the veins acquire a bulk 
which creates an uncomfortable sense of dragging weight, or burning pain, 
there are several measures for affording relief and preventing an increase of 
the disease. 
Whatever will impart tone to and stimulate contractility in the dartos and 
cremaster muscles will contribute much to palliate the symptoms. 
With this object in view, the parts should be dashed two or three times a 
day with cold water, or they may be switched as often with a wet towel. A 
light beating of the scrotum with a piece of rubber tubing for twelve or fif- 
teen minutes every day has also an excellent effect in causing the scrotum 
to contract. An accurately fitting suspensory bag must be worn,-one which 
will keep the parts well drawn up; and, in addition to these measures, the 
bowels must be kept regular, all excessive exercise avoided, particularly 
during warm weather, and all heavy lifting abstained from. The use of ergot 
internally continued for several weeks will also contribute to the contraction VARICOCELE. 
565 
of both the vein and the scrotum. When the ordinary supporting bag 
does not give sufficient relief, the suspending one of Mr. Morgan, of Dublin, 
can be substituted with great advantage. (Fig. 1335.) This consists of a 
piece of webbing, cut so as to conform to the 
shape of the affected side of the scrotum, and 
supplied with a tongue of chamois leather, a 
lacer, and two suspenders. The lower end of 
the bag has a lead wire sewed in its hem, which 
aids in keeping the sling in place and offering 
a fixed point of support. The affected testicle 
and its scrotum are elevated, so as to empty the 
veins of their blood, and then placed within the 
bag and retained by the lacer bringing its sides 
together. The suspenders are next buckled 
into a bandage or band surrounding the body. 
By this ingenious plan the bottom of the scro- 
tum is turned upward, a position most favor- 
able for emptying the veins. The same end 
can be attained, though less satisfactorily, 
by encircling the affected side with adhe- 
sive strips, while the scrotum is kept raised, after which the suspension 
can be effected by a loop of plaster placed vertically over the opposite 
sides of the circular strips, through which loop a strip of bandage can be 
passed, and its ends tied to a band worn round the abdomen. (Fig. 1336.) 
Mr. Wormaid attempted to supply the needed sup- 
port by drawing the redundant tissues at the lower 
end of the scrotum through a metal ring of soft 
silver wire lined with chamois, until the testicles 
and veins were crowded up against the pubes, 
when the sides of the ring were pressed togethei* 
with sufficient firmness to retain the instrument 
in place. This plan is not altogether free from 
danger, as the included tissues have been known 
to slough from the pressure to which they were 
subjected. Independently of this, the appliance is 
worn with considerable discomfort to the patient. 
Pressure of the spermatic veins in the external 
abdominal ring has been followed in some instances 
with very satisfactory results. At first sight this 
plan would seem rather calculated to aggravate 
the difficulty, by the impediment placed in the 
way of the blood returning from the dilated vessels 
into the abdomen. This is really the case so far 
as the affected veins are concerned, but the object 
is to direct the blood back by other and smaller 
channels, and thus take off the weight from the 
diseased ones. The best plan of applying this compression is by a truss 
having a ring with a small central pad, which will fit into the external 
abdominal ring or between the pillars of the tendon of the ex- 
ternal oblique muscle. (Fig. 1337.) 
There are cases of varicocele where, in consequence of the phys- 
ical inconvenience experienced and the disturbed mental condition 
of the patient, disqualifying him from any pursuit and making 
his life miserable, the question of operation must be considered. 
On this subject there is considerable diversity of opinion among 
surgical writers. Often this morbid state of the mind, which also 
leads its victims to magnify the local suffering, is the result of 
ignorance of the nature of the disease, or has been developed by injudicious 
counsel of friends; and, where this is the case, a few words of explanation 
Fig. 1335. 
Morgan's suspensory bandage or sling 
applied. 
Fig. 1336. 
Suspensory of adhesive plaster. 
Fig. 1337. 
Pad for vari- 
cocele. 566 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
and encouragement from the physician will restore mental quietude. If this 
cannot be done, there remains only one course to be pursued, and that is, 
to attempt an obliteration of the veins by an operation. I say attempt, 
for it is very rarely that this can be done perfectly. What, therefore, is 
called the radical cure of varicocele must be accepted in a restricted sense, 
as in most instances it will be partial, though sufficient to leave the patient 
in a much better condition, mentally and physically, than before its per- 
formance. 
Subcutaneous ligature of the spermatic veins, first tested by M. Davat on 
animals, is an operation free from danger, and one which I have practiced 
for twenty years without having witnessed, in a single case, any alarming 
symptoms. The steps of the operation, after the etherization of the pa- 
tient, consist first in removing the hair from the scrotum, after which the 
cord is grasped between the thumb and the index and middle fingers, about 
one inch below the external abdominal ring, and slid backward and forward, 
until the vas deferens is discovered and slipped behind the remaining con- 
stituents of the cord. This duct, by its hard, wire-like feel, is readily recog- 
nized, and, as it is pressed back, the artery with which it is closely associated 
accompanies it. If the manipulation has been successful, the veins are now 
in front of the grasp of the thumb and index finger, and the vas deferens and 
artery are behind it. A stout acupressure-needle should now be thrust through 
the cord, between the veins and the duct. A needle, armed with a double 
hempen thread well waxed, is then entered at one of the perforations made 
by the pin, passed in front of the veins, between the latter and the skin, and 
made to emerge at the other perforation of the pin. The operation is com- 
pleted by slipping the loop of the double ligature over one end of the pin 
and tying its free ends over the other, during the tightening of which both 
extremities of the thread slip within the integument and become strictly 
subcutaneous (Fig. 1338). A cork can now be placed over the sharp end of 
the pin, and the scrotum kept elevated by 
a small cushion. 
The patient must remain in bed for eight 
days and use a moderately spare diet. On 
the seventh day the ligature is to be removed, 
which is readily accomplished by withdraw- 
ing the pin. 
By this plan the thread can be detached 
at any time without waiting for it to cut 
through the included vessels. After the pin 
and ligature have been taken away, the pa- 
tient should remain in bed for another day, 
when he may be allowed to rise; but he should 
continue to wear for two or three weeks a 
suspensory bandage. 
A great number of operations of a some- 
what similar nature have been employed by 
different surgeons, none of which, however, 
has any advantage either in simplicity of ex- 
ecution or in permanency of results. 
The earliest procedure of the kind consisted in thrusting through the 
scrotum a pin, between the vas deferens and the dilated vessels, and then 
passing a thread, in the form of the figure 8, over its extremities and drawing 
it sufficiently tight to strangulate the varicose vessels. This operation, 
which was practiced for some time by prominent French and English sur- 
geons, among them Velpeau and Fergusson, was improved by Mr. Lee, who 
used two pins instead of one, leaving a space between them of about one 
inch, thus rendering the ligature of all the diseased veins more certain. On 
the third day following he divided the veins subcutaneously, or between the 
two ligatures. 
Fig. 1338. 
Scrotum laid open to show the subcuta- 
neous ligature of the spermatic veins; vas 
deferens behind the pin. ABSENCE OF THE TESTICLES. 
567 
Curling, after ligating according to the above plan, introduces a delicate 
tenotome flatwise beneath the veins, and, turning its edge forward, divides 
the vessels between the two pins at the time of the operation. 
Vidal, after passing a silver pin between the veins and the vas deferens, 
carried a needle, bearing a silver thread, through the openings made by the 
pin, but between the integument and the affected vessels, and constricted the 
latter by first twisting the silver wire round the end of the pin and after- 
wards turning the pin on its axis, thus rolling the veins round its shaft. 
Ricord's method consists in passing two double ligatures in opposite direc- 
tions, but through the same holes, one between the veins and the vas deferens 
and the other between the veins and the skin ; the free ends of each double 
thread are next passed through the loops of its fellow-ligature, when, by 
making a sufficient amount of traction, the strangulation is effected. 
Wood's plan is to use subcutaneously a wire for embracing the veins, 
which is tightened by a spring, to which the ends of the metallic thread are 
fastened. 
Sir Astley Cooper recommended and practiced excision of a portion of the 
redundant scrotum for the relief of varicocele, and more recently the same 
procedure has been advocated by Henry, of New York; but the operation has 
met with little favor. Aside from the probability of the integument becoming 
again elongated, there is considerable risk of concealed hemorrhage occurring 
between it and the tunica vaginalis, unless very great care has been taken to 
secure the vessels. 
This accident is rendered less likely to occur by using the clamp of Henry, 
or by repeated transfixion of the scrotum by means of a long acupressure- 
pin, as advised by Hutchison, of Brooklyn. 
Castration and excision of the veins have been resorted to in bad cases of 
varicocele, but no surgeon at the present time would doubt for a moment the 
impropriety of such operations. A modified form of excision has been advised 
by Annandale, in which, after cutting out a portion of the principal vein, the 
bleeding is controlled by acupressure. 
A question of some moment in connection with operative procedures for 
the obliteration of varicose spermatic veins is, What is their effect on the 
testicle? Are such operations followed by atrophy of the glands? I have 
never seen any such change, and I think this accords with the experience of 
surgeons in general. Were the chief artery included in the ligature, such an 
effect might be anticipated ; but, as I have stated, this vessel, by its contiguity 
to the vas deferens, escapes injury. The celebrated French surgeon Delpech 
was assassinated by a man whose spermatic veins he had tied for the cure of 
a varicocele, on account, as was represented by the criminal, of the testicles 
having become atrophied after the operation. 
The dangers to which an individual is exposed who may be in ill health 
at the time of the operation for varicocele are phlebitis, erysipelas, and 
pyaemia. 
Anomalies of the vas deferens are of different kinds. The duct may termi- 
nate in a blind pouch contiguous to the testicle, or it may have no connection 
either with the testicle or with the seminal vesicles. This was the condition 
in Dr. Turner's case.* Brugnone notes one instance in which the duet and 
the epididymis were both absent. 
Affections of the Testicle and its Tunics. 
Absence of the Testicles.-A number of cases of this nature have been re- 
corded by writers, particularly by the French. Many of these were, perhaps, 
examples of atrophy, or of undescended testicle, rather than of congenital 
absence. This atrophy is liable to occur both before and after birth. There 
are, however, a number of well-established instances in which one or both 
testes have been entirely wanting. Most of these have been collected by 
•* Curling on the Testes, p. 7. 568 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
Goddard.* When one of the testes is not present, the term monorchid is used 
to express the condition. When both glands are absent, the term cryptorchid 
is employed. 
Sometimes there is only a partial absence of the testes,-that is, the scrotum 
may contain only the epididymis, with or without the vas deferens; at other 
times the vas deferens alone is present. 
Supernumerary testicles have been mentioned by Schaarf, Blegney, Blasius, 
and others. The first-named writer describes a man who was believed to 
have five, and the person whose case is recorded by Blegney is represented to 
have possessed four glands. Twice have I seen the globus major so detached 
from the body of the epididymis as to resemble strikingly a third testicle. 
As no dissections, so far as I know, have been made with a view to verify 
the existence of supernumerary testicles, the genuineness of the cases reported 
may very well be doubted, the body supposed to be the testis having possibly 
been a cyst, a hernia, or a tumor of some kind. 
Anomalies of position.-The absence of one or both testes from the scrotum 
is no evidence that these organs do not exist. Frequently they remain un- 
descended, either in the abdomen or in some portion of the inguinal canal. 
When in the latter situation they are liable to be mistaken for hernia, and 
are indeed sometimes associated with that affection. 
The testicles at birth frequently fail to make the complete descent of the 
canal into the scrotum. They may remain in the abdomen, below the kidney, 
in the inguinal canal, or just external to the external abdominal ring. The 
left testis remains undescended more frequently than the right. This defect 
is quite common. 
Weisberg, in an examination of 103 infants, found 21 in whom one or both 
testicles were immediately external to the abdominal ring, and in 12 one or 
both were in the abdomen. Sometimes in the descent the testicle goes 
astray, and, instead of following the inguinal canal, passes into the femoral 
canal, and appears through the saphenous opening on the front of the thigh. 
In several instances the testicle has been lodged in the perineum. It is 
difficult to conceive how the gland could reach this locality except by a con- 
tinuity of the integuments of the perineum with those at the external ab- 
dominal ring. Mr. Curling, who has seen eight cases of the kind, explains 
the anomaly by assuming the attachment of the middle part of the guber- 
naculum to the integuments of the perineum. Similar displacements have 
been witnessed by Hunter, Goddard, Vidal, Ledwich, Adams, Bryant, and 
myself. 
If the descent is not completed before puberty it rarely occurs subsequently. 
In many cases it takes place about the period of birth. 
I have in two instances witnessed the gland undergo singular changes in 
position, one day being in the scrotum, and the next in the inguinal canal, 
having been retracted by the cremaster muscle. Should the complete de- 
scent be delayed longer than eight or ten months after birth, it is liable to 
be accompanied by a hernial protrusion. Where the testicle is permanently 
detained in its unnatural position, it generally remains undeveloped, the 
tubuli seminiferi being defective and their secretion devoid of spermatozoa. 
This does not necessarily compromise eithei- the fruitfulness oi* the vigor of 
the genital organs. The deficiency is usually provided for by an increased 
enlargement of the other or normally-placed testis. 
Previous to a microscopic examination of the seminal fluid, it would be un- 
safe to pronounce positively as to the barrenness of an individual in whom 
both testicles have failed to reach the scrotum. If, upon such an inspection, 
the semen is found devoid of spermatozoa, it will establish the fact of steril- 
ity, though not necessarily of impotency. A retained testicle must be re- 
garded as an unfortunate circumstance, as the gland is liable to disease, 
occasionally of a malignant nature, especially when it remains in the inguinal 
canal. In this situation it is exposed to severe compression during the many 
* Gazette Medicale de Paris, 1860, pp. 217, 435. UNDESCENDED TESTICLE. 
569 
powerful contractions of the abdominal muscles, in consequence of which it 
may be attacked by neuralgia or by inflammation, the disease extending to 
the peritoneum and destroying the patient. It will also predispose to hernia. 
In some instances, where the testicle has passed from the abdomen through 
the internal ring into the inguinal canal, in making ineffectual efforts to 
descend it has, in consequence of the incarceration to which it was subjected, 
given rise to symptoms which closely simulated strangulated hernia, as pain, 
abdominal distention, and vomiting. 
Diagnosis.-The occasional descent of a retained testicle, its appearance 
external to the abdominal ring, and its subsequent spontaneous retraction, 
or its retrocession either by recumbency or by pressure, are signs belonging 
to inguinal hernia, with which it might be confounded. But when the un- 
tenanted scrotum, the peculiar ovoidal form of the tumor, its firmness, and 
the sickening sensation caused when it is compressed, together with the 
absence of impulse in coughing, are considered (none of which signs belong 
to rupture), there will be little difficulty in reaching a correct conclusion. 
Instances have occurred, however, in which the diagnosis has been rendered 
exceedingly embarrassing in consequence of the swelling following an in- 
flamed undescended testicle having reached the scrotum before surgical aid 
was sought, and in which it was impossible by feeling to ascertain whether 
the testicle was in its proper position. 
Just such a complication came under the observation of Pott, who was 
called to see a patient supposed to be suffering with strangulated hernia. In 
the hands of a less careful surgeon an operation would doubtless have been 
performed. 
I operated on a boy about sixteen years of age, who bad a strangulated 
hernia following an undescended testicle. On opening the canal, both the 
intestine and the testicle were found, the latter quite normal in size and 
appearance. The stricture was divided, the bowel returned, and the testicle 
brought down into the scrotum without difficulty. The boy made a rapid 
recovery. Whether, after returning to his occupation, which was that of a 
plumber, the gland remained in the scrotum or not I am unable to say, as he 
passed out of my observation. 
When the testicle is placed in front of the thigh or in the groin it may be 
confounded with bubo, and I know of two such instances in which it nar- 
rowly escaped being punctured, under the supposition of its being a sup- 
purating gland. If the scrotum on the affected side is found empty it is not 
probable that any mistake will be committed. 
The causes which operate to prevent the descent of the testicle are not 
always obvious. Among those which have been assigned are adhesions, 
either within the abdomen or within the inguinal canal, some defect in the 
contracting property of the gubernaculum testis, or in the capacity of the 
inguinal canal, and preternatural shortness of one or more of the con- 
stituents of the cord. 
Treatment.-As long as the gland remains high up in the inguinal canal, 
and occasions neither inconvenience nor suffering, there can be no necessity 
for any interference. When it is encountered below the external ring, an 
effort may be made to coax or constrain its descent. This is done by gently 
dragging it downward, and, to prevent its retrocession into the canal, by 
guarding the ring with a truss having a soft pad. Should a hernia follow 
the testicle, and the latter can be detected external to the canal, the truss 
will answer the double purpose of retaining the rupture and preventing the 
retraction of the gland. 
When the testicle is subject to violent retraction, producing severe distress, 
it is not improbable that, by exposing the cord and dividing the fibres of the 
cremaster muscle, relief might be obtained and the descent of the organ be 
favored. 
Operations have been performed with a view to placing the testicle in the 
scrotum by Partridge, by Curling, and by Adams, but without success, as the 570 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
attempts (which consisted in dividing such adhesions as were thought to 
check the descent) were followed by the death of the patients. It is some- 
what singular that in none of these operations did it occur to the surgeon to 
divide the cremaster muscle. If the testis follows the femoral canal and ap- 
pears in front of the thigh, it is best, if possible, to press it back through the 
saphenous opening into the abdomen, applying a truss to prevent its return. 
Should the abnormally-placed testicle be productive of repeated attacks of 
pain or other distress, the welfare of the patient will be best consulted by 
extirpating the gland. Other displacements of the testicle have been noticed, 
in which the epididymis is attached to the anterior instead of the posterior 
part of the testis (inversion of the testicle), or in which the gland is reversed 
with the vas deferens arising from the small end of the epididymis. 
Hydrocele. 
Hydrocele consists in an abnormal accumulation of fluid in the cavity of 
the tunica vaginalis testis. It is an exceedingly common affection, occurs 
with about equal frequency on both sides, and is occasionally met with simul- 
taneously in both vaginal tunics. Hydrocele may be either congenital or 
acquired. It is also unilocular, when the fluid is contained in the common 
cavity of the tunica vaginalis; bilocular, when that cavity is divided into two 
sacs by adhesion of a portion of its walls; and encysted, when the fluid is in 
a sac independent of the tunica vaginalis. 
Hydrocele is met with at all periods of life; in childhood generally during 
the first two years after birth, and later in life from thirty to sixty. It is 
the result usually of chronic inflammation, though there are not wanting 
instances of acute hydrocele. The latter variety may follow an injury to the 
scrotum or to the epididymis. Congenital hydrocele may exist independently 
of an inflammatory origin, the fluid accumulating in the sac by gravity, in 
consequence of the communication between the tunica vaginalis and the 
cavity of the peritoneum not being interrupted. 
The causes of hydrocele are often not appreciable, but in many instances 
the disease can be traced to blows, to violent muscular efforts in lifting, to 
the straining which, in stricture of the urethra, is often required to pass the 
urine, to failure in the funicular process of the peritoneum to close, and to 
changes in the vaginal tunic incident to advanced life. 
These structural alterations consist in thickening, and in the presence of 
loose, fibrous, cartilaginous, or bony bodies which are adherent to the inner 
surface of the membrane, and are not unlike those seen in certain joints, as 
the knee. The disease is often seen in connection with syphilitic sarcocele, 
or sarcoma of the testis. A common cause of this affection is relaxation in 
the tissue of the scrotum from intense and protracted heat; hence the great 
frequency of hydrocele in India, Brazil, and other hot countries. Hereditary 
influences seem to have sometimes evoked the disease, the most notable ex- 
ample being that given by the late Sir Henry Holland, in which, in one family, 
three or four successive generations suffered from this complaint. 
Epididymitis is frequently followed by hydrocele. The fluid of a hydro- 
cele is usually of a straw color, quite transparent, coagulable by heat, and in 
its chemical constitution almost identical with the serum of the blood. An 
analysis made by Bostock of 100 parts of this fluid yielded of water, 91.25 
parts; albumen, 6.85; non-coagulable matter, 1.1; and saline matters, .8. 
Occasionally, instead of presenting the ordinary transparent appearance, 
the fluid is dark-colored, a condition which is due to the presence of dis- 
organized blood-corpuscles, and, when not the result of an injury, is often 
associated with a diseased condition of the vaginal tunic. 
The milky appearance of the fluid of hydrocele, produced by the presence 
of fatty matter, described by authors, I have seen four times. The source 
of this fat is believed by Klebs to be fatty degeneration of the cells lining 
the serous tunic. Cholesterin is not unfrequently seen in the serum, pre- ENCYSTED HYDROCELE. 
571 
senting the appearance of glistening particles. In encysted hydrocele the 
fluid is frequently of a milky or pearl color and contains spermatozoa. The 
lattei* I have seen in ordinary hydroceles, and often, no doubt, these cells 
reach the fluid in consequence of a slight puncture made by the trocar when 
the sac is carelessly tapped. 
The amount of fluid present in hydrocele varies very greatly, the common 
quantity being about ten or twelve ounces. The largest tumor of this nature 
which I have seen measured twenty-one inches in circumference, and con- 
tained about thirty-eight ounces of water. The extraordinary case of Gibbon, 
from whom Cline removed six quarts of fluid, is familiar to most surgical 
readers; though even this large quantity is less than that in a case mentioned 
by Dr. Jones,* in which two gallons were drawn. 
In 1000 cases of hydrocele treated at the Native Hospital, in Calcutta, and 
analyzed by Dr. Dujat, the largest quantity of fluid observed in any single 
case was one hundred ounces. 
Opportunities for examining the structural changes which the tunica vagi- 
nalis undergoes in hydrocele have occasionally been offered, and in old-stand- 
ing cases these alterations are very marked,-not unlike those which are 
witnessed in the pleura after repeated attacks of inflammation. The tunic is 
thickened with plastic transudations, is rough and fibrous, and often contains 
calcareous matter. These changes are chiefly limited to the reflected or 
scrotal part of the membrane. 
Occasionally the sac of the vaginal tunic is divided into two compartments 
by a partition, or by an adhesion of a portion of its two sides, imparting in 
some instances an hour-glass shape to the tumor. This septum may be eithei* 
complete or incomplete. I have tapped one chamber and drawn off the fluid 
without affecting the size or contents of the other in the least. The testicle, 
though surrounded by the serous accumulation, experiences no injury; but, 
when the collection is large, it may be somewhat flattened in shape. 
When the testis is found diseased, the hydrocele is generally an effect and 
not the cause of the glandular trouble. In addition to the morbid changes in 
the tunica vaginalis, there will, in old cases of hydrocele, be others in the 
surrounding parts, as hypertrophy of the dartos and connective tissue. 
Several cases of hydrocele have been recorded in which the sac extended 
up into the abdomen; the most remarkable of these is one given by Rochard,f 
in which the tumor, extended downward as low as the knees and upward 
through the canal into the abdomen, as high as the umbilicus. Almost one 
gallon of a dark-greenish fluid was drawn when the swelling was tapped. I 
have in at least two instances seen the vaginal hydrocele extend into the 
inguinal canal. 
Encysted Hydrocele.-In that variety of the disease in which the fluid is 
contained in a sac between the serous membrane and the epididymis, or be- 
tween the former and the tunica albuginea, the cysts are generally multiple; 
they are commonly found in persons over forty-five or fifty years of age. In 
a collection of testes, numbering about thirty-five, in the museum of the 
University, I found six glands affected with cysts. These cysts seldom 
attain a size larger than that of a pea. They contain a clear fluid, and often 
have a pedunculated shape. 
A much larger cyst is sometimes met with, having its origin more deeply 
situated beneath the membrane surrounding the epididymis, and containing, 
in some instances, two or three ounces of a colorless, non-coagulable fluid. 
The fact that these cysts usually contain spermatozoa has given rise to con- 
siderable speculation as to the manner in which these cells find their way 
into the sac. Originating as they do in the parenchyma of the epididymis, 
it is most probable, as Curling has stated, that the intrusion of these bodies 
* Gross's Surgery, vol. ii. p. 851. 
f L'Union Medicale, Jan. 27, 1859, p. 70 (Curling). 572 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
is the result of accident, from the rupturing of one of the seminiferous tubes 
of that body. Other writers, as Luschka and Klebs, have thought that the 
cyst itself is only a dilatation of these tubes. 
Symptoms.-Ordinary hydrocele of the tunica vaginalis is usually slow in 
its formation. The swelling is ovoidal or pyriform in shape, smooth, tense, 
elastic on pressure, fluctuating, and without pain, redness, or other discolora- 
tion. Occasionally the exetrnal contour of a vaginal hydrocele is irregular, 
perhaps constricted in the centre and dilated at each extremity,-a condi- 
tion due to some inflammatory thickening of the sac rendering it unyielding 
at certain points. 
The scrotum, instead of hanging limp, projects from the body, and if 
pressed back between the thighs immediately springs forward on being re- 
leased. When tested by light it is found to be translucent. This last char- 
acteristic is most satisfactorily ascertained by examining the patient in a 
dark room: while a candle or lamp is held on one side of the swelling, the 
surgeon stoops down on the other side, making the scrotum tense with one 
hand, while the other is placed in a vertical position on the upper surface 
of the tumor, in order to intercept the peripheral rays of light. If the 
sac contains serum, its translucency will be discovered at once. The testicle 
in hydrocele is situated posteriorly in the vaginal tunic, at about the 
junction of the middle and lower thirds of the scrotum, except in cases of 
inversion of the testes, when the latter will be found in front of the sac. 
When the contents of the hydrocele are milky in color, or when they are 
mingled with blood, or when the sac of the vaginal tunic has become thick- 
ened and rough from repeated plastic deposits, the translucency of the swell- 
ing is lost, and the use of the grooved needle will be required. However 
confident the surgeon may be with regard to his diagnosis of hydrocele, the 
light test should never be omitted, as he is thereby enabled to ascertain the 
exact situation of the testis, and thus avoid inflicting any injury on the organ 
when the trocar is introduced. 
Diagnosis.-Hydrocele in the adult is liable to be confounded with hernia, 
varicocele, hiematocele, sarcocele, and encephaloid disease of the testis. 
Errors in diagnosis are so common that it will not be out of place to consider 
the subject carefully. 
The leading differences between hydrocele and hernia will be found in the 
following table: 
HYDROCELE. 
The swelling in hydrocele commences at the 
most dependent part of the scrotum, and gradu- 
ally ascends towards the external ring. 
Hydrocele, when once formed, is a permanent 
enlargement, and not influenced by position. 
The form of the swelling is cylindrical or ovoid. 
The tumor on percussion yields a flat sound. 
Palpation communicates a sense of fluctuation, 
and coughing causes no succussion or impulse to 
the fingers. 
The tumor has a tense look, stands off from 
the body, and if pressed towards the perineum 
and then released springs back to its original 
position. 
The swelling can be illuminated by artificial 
light, and becomes translucent. 
HERNIA. 
The swelling in hernia commences above, at 
the external ring, and descends towards the bot- 
tom of the scrotum. 
Hernia (if reducible) recedes and disappears 
when the patient assumes the recumbent posture, 
and reappears when he is in the erect position. 
The form of the swelling is pyriform or round. 
Should the contents of the sac consist of intes- 
tine, the percussion-sound will be resonant. 
Fluctuation is absent, and succussion in cough- 
ing or straining is noticeable. 
The integuments do not appear tense, and the 
tumor is pendent or pendulous rather than prom- 
inent. 
In hernia the swelling is opaque. 
With so many points of distinction between the two diseases a mistake 
appears to me to be inexcusable, and yet, I doubt not, the experience of 
every surgeon furnishes many examples of this error. A short time since I 
was called to see a case of hernia into which a trocar had been thrust, the 
tumor having been supposed to be a hydrocele. ENCYSTED HYDROCELE. 
573 
The chief diagnostic points of varicocele and hydrocele are as follows: 
HYDROCELE. 
Hydrocele presents a smooth and uniform sur- 
face. 
Hydrocele, on pressure, appears to be homoge- 
neous in consistence. 
Hydrocele is not affected by recumbency. 
Hydrocele rarely causes pain along the cord or 
in the lumbar region. 
VARICOCELE. 
Varicocele presents an irregular surface. 
Varicocele feels as though made up of a con- 
geries of contorted cords. 
Varicocele disappears when the patient assumes 
the recumbent position. 
Varicocele frequently produces pain in the 
course of the inguinal canal and in the loins. 
In consequence of a blow or fall, in which the scrotum is injured, a free 
hemorrhage occasionally takes place within or without the cavity of the 
tunica vaginalis, forming a hsematocele. To distinguish this from hydrocele 
the following comparisons may be made: 
HYDROCELE. 
Hydrocele appears usually without having 
been caused by external violence. 
Hydrocele is elastic and rather light. 
Hydrocele is translucent. 
The integument in hydrocele is free from dis- 
coloration. 
HEMATOCELE. 
Heematocele generally is produced by an injury. 
Haematocele is more solid and heavy. 
Haematocele is opaque. 
The integument in haematocele is often discol- 
ored in consequence of the injury, and always so 
when the extravasated blood is external to the 
tunica vaginalis. 
Sarcocele and encephaloid disease of the testis, while they have a certain 
resemblance to hydrocele, are not so likely to be confounded with the latter 
as the affections already described. The characteristics which belong to sar- 
cocele, and which are quite sufficient to establish the diagnosis, are hard- 
ness, irregularity of surface, increased weight, and the absence of fluctuation 
and translucency. Encephaloid disease of the testis, in consequence of the 
tendency to the formation of cysts filled with fluid and to serous effusion 
into the tunica vaginalis, possesses in some respects a stronger resemblance 
to hydrocele than does an enlarged testicle. The differential features will 
appear in the rapid growth, hard, irregular, nodulated surface, implication 
of the inguinal glands, want of general translucency, pronounced cachexia, 
and rapid loss of flesh and strength,-phenomena which belong to malignant 
disease. 
Treatment.-The treatment of hydrocele may be either palliative or rad- 
ical. Spontaneous cures of this affection in a child are not rare. Occasionally 
it has disappeared on the supervention of an attack of inflammation of the 
testicle. In young children it is not uncommon for the fluid to be absorbed. 
As the disease is not dangerous, and becomes annoying only by its bulk, 
there are many persons who are content with such treatment as will afford 
temporary relief. There are other cases in which, on account of a diseased 
state of the testicle or of the tunica vaginalis, to attempt anything more 
than this would be improper. 
When the object is palliation, the patient may be tapped and the fluid 
Fig. 1339. 
Trocar. 
drawn off. The instrument necessary for the operation is a small trocar and 
canula. (Fig. 1339.) 574 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
The patient sitting with his buttocks over the front edge of a chair, or 
standing erect, or lying on his back, the surgeon grasps the tumor in one 
hand, in order to render the tissues tense, and with the other plunges 
the trocar into the anterior part of the sac, at the junction of the middle 
and lower thirds of the scrotum, and in a direction inward and upward, in 
order that no damage may be done to the testis. Any considerable vein 
on the surface of the skin should also be avoided. The absence of resist- 
ance will indicate that the instrument has entered the vaginal tunic, when, 
upon withdrawing the trocar from the canula, the contents of the sac will 
escape. The serum having been removed, the canula is to be drawn out. The 
small and insignificant 
puncture will require 
no dressing, or, if a 
few drops of blood es- 
cape and it is necessary 
to prevent the linen 
from being stained, a 
little strip of adhesive 
plaster may be used 
to cover the part. (Fig. 
1340.) 
Acupuncture, recom- 
mended first by Mr. 
Lewis, of London, has 
been employed as a sub- 
stitute for tapping by 
the trocar. Two or 
three punctures are 
made into the sac by 
a needle, and the fluid 
finds its way into the 
cellular tissue of the 
scrotum, forming a diffused swelling. The operation may be repeated from 
time to time. 
Radical Treatment.-There are several different methods of treating 
hydrocele with the intention of producing a radical cure. One surgeon lays 
open the swelling and excises a portion of the tunica vaginalis; another in- 
troduces a seton ; a third will advocate exposing the sac and mopping it well 
with some stimulating fluid ; while a fourth will express his preference for 
injection. All of these plans, doubtless, succeed, and I have employed all of 
them. The most simple of all methods is injection. It is an operation which 
can be done quickly, involves no great amount of skill in its execution, is 
followed by a short continuance of pain, and, above all, is almost uniformly 
successful in effecting a cure. I give to this plan an unqualified preference, 
not on hypothetical or presumptive grounds, but for a reason which alone 
should influence the surgeon in dealing with questions affecting human health, 
namely, the uniform experience of success. 
The explanation of the well-known discrepancy of views in regard to this 
simple measure of injection in hydrocele lies not in the method, but in the 
manner of its execution. When I am informed, on credible authority, that 
by a given plan for the cure of a particular disease only 3 cases failed in 1148 
patients,* 1 accept it, and try it; and if I do not meet with similar success 
in my own experience, I infer that some important omission in its employment 
has been made. 
A few silver threads deposited in the sac of a hydrocele may seem very 
artistic; the excision of the vaginal tunic will yield more blood and attract 
more attention than an unpretending injection; but, after all, with the last 
the disability is less and the result as sure. The use of the injection in hydro- 
Fig. 1340. 
Tapping a hydrocele. 
* Froriep, N. Notizen, vol. viii., November, 1836. ENCYSTED HYDROCELE. 
575 
cele is due, according to Dr. Munro, to a surgeon of his own name who served 
in the Scotch army during the beginning of the last century. The remedy 
which he first used was alcohol, afterwards wine. The violent inflammation 
and suppuration which sometimes followed the use of the first brought dis- 
credit upon the practice, especially among British surgeons. Mr. Pott speaks 
of it as an operation which, happily for mankind, has been laid aside: he lived 
long enough, however, to alter his opinion. In France they continued to 
employ injections, using milder fluids, and securing favorable results, as stated 
by Sabatier, until, finally, the practice became popular in England, mainly 
through the labors of Sir James Earle. The opposition manifested to this 
plan arose from different notions as to subsequent effects. Mr. Sharp was 
afraid of the violent symptoms produced by the spirit of wine. Mr. Doug- 
las thought that the distance between the two layers of the vaginal tunic 
would render exactness and uniformity in their contact impossible. Le Dran 
adopted the same view. The theories of cure entertained by the two authori- 
ties last named have an extensive prevalence at the present time; that is 
to say, the disease is supposed to be eradicated by an inflammatory consol- 
idation of the two layers of the tunica vaginalis in its entire extent, thus 
obliterating its cavity altogether. 
Whether this ever takes place to such a degree I am unable to say; but 
that it is not necessary for the extinction of the disease I very well know, hav- 
ing had an opportunity of examining the parts in a case where the injection 
had been employed. Bands of organized lymph were found intersecting the 
cavity of the tunica vaginalis at several points, and a very limited adhesion 
existed at two or three other localities, but the largest portion of the walls of 
the sac remained separate, its surface, however, entirely changed, having an 
irregular, dull, dry, and fibrous appearance. The fluid used by Earle w'as 
port wine diluted one-third with a decoction of rose-leaves. The greatest im- 
provement in the injecting material, however, consisted in the introduction 
of the tincture of iodine, an agent possessing singular efficacy, without ten- 
dency to excite suppuration, and producing, when properly used, just that 
degree of inflammation which yields adhesive lymph. The credit of its 
application to the treatment of hydrocele in France belongs to Velpeau, 
although it is alleged to have been well known to the physicians of India. 
If it has failed to answer the expectations of surgeons, the fault is not in the 
iodine, but in the manner in which it has been used. Some advise that this 
agent should be allowed to remain only a short time in the sac, say a few 
minutes, and then withdrawn; others think that the iodine should be largely 
diluted with water before using it as an injection, and should be employed 
in such a quantity as to distend well the tunica vaginalis. Just here, I 
think, lies the cause of failure, when failure occurs. The undiluted officinal 
tincture of iodine should be throzon in and allowed to remain. The India phy- 
sicians, it is said, adopted this course, and Mr. Syme strongly insists upon it, 
forcibly arguing against all attempts to resuscitate the seton in any form 
whatever. 
I have done this operation a great many times, and always with a suc- 
cessful result, when its details have been observed. I can recall one failure 
only; a case where the hydrocele was of unusual magnitude, measuring six- 
teen inches in circumference, and with a vaginal tunic greatly thickened. 
This case was cured by excision, although, perhaps, had a larger quantity of 
the iodine been used, the result might have been different. 
Operation.-Making the walls of the scrotum tense in front of the testicle, 
the surface is carefully inspected, with a view to avoid any venous trunks, 
and the trocar thrust in a short distance from the most dependent part of the 
swelling and in a direction somewhat oblique to its longitudinal axis. The 
absence of resistance will indicate when the cavity of the tunica vaginalis 
is reached. The trocar is now withdrawn, leaving the canula in situ, when 
a stream of straw-colored fluid will escape into the cup. After emptying 
the sac of all the fluid, the testicle should bo examined with a view to dis- 576 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
cover if there is any enlargement or undue sensibility which might render it 
improper to attempt a radical cure. Finding nothing of this nature, the 
nozzle of the syringe, charged with two and a half drachms of the tinc- 
ture of iodine, is inserted into the canula, and, pushing forward the piston, 
its contents are emptied into the serous sac. The parts are now rubbed to- 
gether, so as to diffuse the liquid over the entire surface of the membrane, 
and the canula withdrawn, leaving all the tincture in the sac. The patient 
begins to complain of a sharp pain, which in a short time will reach the back 
and produce perhaps a sickening sensation. This is the operation by injec- 
tion,-exceedingly simple and almost infallible. The patient should now be 
returned to his bed, and something placed under the scrotum to give it the 
requisite support. If the pain continues long and is very severe, he should 
have a quarter of a grain of morphia. His diet should be moderately re- 
stricted for two or three days. By the third day the swelling will have in- 
creased to nearly its original size, and it will so remain for probably twenty- 
four or thirty-six hours, when it will begin to subside. At the end of the 
seventh day the patient may put on a suspensory bandage and get out of 
bed, going about as he may feel able. 
In three or four weeks the swelling will have disappeared and the cure 
will be accomplished. Double hydroceles may be tapped and injected at the 
same time with entire safety. 
Infantile Hydrocele.-Another form of hydrocele is that belonging to infan- 
tile life, and in it, as in the hydrocele of the adult, the disease is situated in the 
tunica vaginalis. In one variety of infantile hydrocele there is an anomaly 
of development, a continuity between the cavities of the tunica vaginalis 
and the abdomen, in consequence of which the serum from the peritoneum 
trickles down along the cord into the vaginal tunic, and forms the so-called 
congenital hydrocele of the tunica vaginalis testis. 
It is supposed by many that in congenital hydrocele of the vaginal tunic, 
as in hydrocele of the cord, the communication between the abdomen and 
the tunica vaginalis is free; in other words, that the cord lies loose in the 
funicular process. Such, however, is not the case. Though not adherent at 
all points, this process is in contact with the cord in the entire extent of the 
inguinal canal. There is considerable diversity of opinion as to the proper 
treatment of congenital hydrocele in its different varieties. Some advise in- 
jections of iodine into the sac after the abstraction of its contents. Among 
the French surgeons alcohol is quite a popular remedy. Should any one be 
tempted to use either of these agents in congenital hydrocele, the continuity 
of the vaginal tunic with the cavity of the abdomen must be remembered, in 
order that pressure may be made at the external ring, to prevent the fluid 
from entering the peritoneal sac, in the event of which the patient would 
probably perish from inflammation. 
There are three plans which I find entirely satisfactory in the management 
of all varieties of infantile hydrocele. 
First. By expectancy.-Many cases get well without any assistance from 
the surgeon, and therefore, unless the tumor steadily increases in size, it may 
be left alone, hoping for such a termination. When the enlargement steadily 
goes on, an effort may be made to secure the absorption of the fluid by the 
external application of a lotion of the muriate of ammonia, or by applying 
the compound solution of iodine. 
Second. By excision.-This consists in making a puncture with a sharp- 
pointed bistoury into the hydrocele and evacuating its fluid, after which the 
tunica vaginalis, which appears in the wound as a white membrane, should 
be seized with a pair of forceps, drawn through the wound, and a small por- 
tion snipped off with the scissors. 
Third. By the seton.-This last method is the one which I generally adopt, 
and which I regard as in every way satisfactory. It is applicable to all vari- 
eties of the disease, and consists in puncturing the sac with a sharp-pointed HYDROCELE IN THE FEMALE. 
577 
bistoury, and along the blade of the instrument introducing a needle armed 
with a single silk thread, which is brought out through the skin of the scro- 
tum and loosely knotted. The seton serves to drain away the serum and to 
develop sufficient inflammation to cure the disease. The thread should never 
be allowed to remain more than twenty-four or thirty hours, after which time 
it must be removed. If this precaution is observed, there will be little risk of 
suppuration, and a cure will almost invariably follow. 
Encysted Hydrocele is generally of slow growth. The swelling begins at 
the posterior part of the testicle, which is situated cither in front of or be- 
neath the tumor, at the bottom of the scrotum. It is tense, follows the move- 
ments of the gland, and is often attended with considerable pain. When the 
enlargement is multilocular the tumor will present an irregular or uneven 
surface. The fluid of encysted hydrocele differs from that of an ordinary 
collection of serum in the vaginal tunic in being as clear and transparent as 
water,-a circumstance which may serve a valuable purpose in forming a 
differential diagnosis between the two diseases. 
The treatment does not differ from that proper in a case of vaginal hydro- 
cele, namely, tapping and the injection of tincture of iodine. As there may 
be several cysts, each separate from the others, the proper plan of procedure 
is, after one sac has been emptied, and before withdrawing the canula, to re- 
introduce the trocar and puncture a second, third, etc., by simply changing 
the direction of the instrument. In the same manner the iodine can be 
introduced. If one of the cysts is quite small it may not be necessary to 
open it, as it will probably be obliterated by the contiguous inflammation. 
A Hydrocele of the Inguinal Canal is occasionally met with dependent on 
the presence of the undescended testicle. A tense, fluctuating swelling in 
this region, irreducible, imparting no impulse to the fingers during coughing, 
and occasioning, when firmly squeezed, a sickening pain, would indicate the 
nature of the disease, especially if the corresponding side of the scrotum was 
untenanted. 
The radical treatment will require the opening of the sac and the removal 
of the faulty testicle. 
Hydrocele of the Sac of a Hernia.-The neck of a hernial sac may become 
obliterated either from the long-continued pressure of a truss or by a portion 
of its contents becoming adherent to its mouth. The pouch below, being a 
serous structure, may become inflamed and dropsical. 
The treatment is the same as that employed in hydrocele of the vaginal 
tunic, namely, by tapping and injection. 
A singular case has been described by Le Bran, in which three varieties 
of hydrocele existed in the same person and on the same side; that is to say, 
a hydrocele of a hernial sac, a hydrocele of the cord, and a similar accu- 
mulation in the common vaginal tunic. 
Hydrocele in the Female.-When hydrocele occurs in the female it is located 
in those parts which constitute the analogues or complements of the sper- 
matic cord and scrotum in the male, namely, in the funicular process of 
peritoneum which invests the round ligament as it lies in the inguinal canal, 
and in the cellular tissue of the labium. 
The diseases with which hydrocele in the female may be confounded are 
hernia, cysts, varicose veins, and oedema. When the fluid is situated in the 
tubular process of the round ligament or in the labium, the varieties of rup- 
ture which it resembles are, in the first case, inguinal, and in the last, obtu- 
rator hernia. The distinction can be established by attention to the following 
particulars. In hernia the tumor will be compressible and reducible, and in 
the act of coughing or straining will communicate to the hand a marked 
impulse. None of these peculiarities belong to hydrocele. In the case of 
vol. ii.-37 578 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
cystic growths the differential points are not so easily recognized; it will, 
however, be found that cysts are sharply circumscribed and project from the 
mucous surface of the labium. The swelling in hydrocele is more diffused 
and extends equally in all directions. In doubtful cases the exploring needle 
will impart much valuable information. In cysts, instead of the fluid being 
clear or straw-colored, it will be dark and often tinged with blood. 
Occasionally the labial veins become varicose, forming a considerable mass 
on the inner surface of the labium. In the recumbent position such a swelling 
subsides or can be readily removed by pressure; the mucous surface presents 
a purple appearance, and the tortuous arrangement of dilated veins can be felt. 
Hydrocele possesses none of these characteristics. (Edema of the labium is 
often occasioned by pressure upon the pelvic or abdominal veins, produced 
by the gravid womb or by ovarian and uterine tumors. Such a swelling pos- 
sesses many characteristics in wide contrast with hydrocele. In oedema there 
is neither fluctuation nor translucency present; the parts have a doughy feel, 
and when pressed upon " pit," retaining for some time the depression made 
by the finger. 
Treatment.-Hydrocele, whether in the sheath of the round ligament or 
in the labia majora, demands no surgical interference so long as the disease 
shows no tendency to increase. If, on the contrary, the accumulation steadily 
progresses, it should be treated by the injection of iodine, after which, if the 
disease is located in the funicular process of the round ligament, a light-press- 
ing truss, with a soft pad, should be applied as soon as the inflammation in- 
cident to the injection has begun to decline, in order that the parts may be 
maintained in close approximation. 
In infantile hydrocele of the round ligament, injections, when used, should 
be very carefully managed. The tubular process of the ligament is likely 
to be open next to the abdomen, and, if so, would permit the fluid to pass 
into the general peritoneal sac. Pressure over the upper part of the inguinal 
canal will prevent such an accident; but it is safer and equally efficient to 
employ the seton, by introducing a single silk thread into the sac for thirty 
hours. Infantile dropsy of the round ligament, however, will in most cases 
undergo a spontaneous cure, or if its disappearance is very slow it may be 
hastened by the application of a truss: in consideration of these facts it is 
better not to operate prematurely. 
When the fluid is situated in the labium the cellular tissue will generally 
be pressed aside and condensed, so as to form a single sac, and in such cases 
the iodine injection will effect a cure with the same certainty as in hy- 
drocele of the tunica vaginalis of the male. Should this not be the case, a 
closer investigation of the growth will probably prove it to be a cyst, in 
which event nothing short of the excision of its sac or wrall will eradicate the 
disease. 
Complications.-The complications which may occur in a hydrocele are: 
First, rupture of the sac from a fall or blow. The fluid escapes into the 
connective tissue of the scrotum and the penis. This accident may be safely 
left to natural processes. The extravasated serum will be absorbed, and 
probably, though not necessarily, a cure will follow. 
Second. Orchitis may arise in consequence either of urethral inflammation 
or of cystitis. The treatment must be directed to the removal of these 
affections without reference to the hydrocele, and the two may disappear 
together. 
Hernia is not unfrequently associated with hydrocele. In the radical treat- 
ment by injection the hernia must be reduced. After the water is removed, 
and during the injection of the iodine, a finger should be held firmly upon 
the cord at the external ring, so as to prevent the liquid from passing into 
the abdomen. 
Other plans for the radical cure of hydrocele have been practiced, the most 
important of which may be enumerated. 
Incision is perhaps the oldest of all operations for the permanent cure of HEMATOCELE. 
579 
this disease. It consists in dividing the tissues of the scrotum until the sac 
is reached, which is then laid open in a direction from the upper to the lower 
part, its cavity stuffed with lint, and the wound allowed to heal by open 
granulation. The operation is not unattended with danger. 
Excision.-By this method the scrotum is incised down to the sac, when 
the latter is to a great extent dissected out and the wound allowed to heal by 
granulation. This operation I have frequently seen practiced, and without 
any bad effects. In the case mentioned in which a very large hydrocele 
had resisted the ordinary measures of cure, in consequence of the great 
thickening and alteration in the structure of the sac, I succeeded in eradi- 
cating the disease by excising the diseased membrane. 
Seton.-The seton, another old plan of treatment, originating with the 
Arabian physicians, is applied by introducing through the front of the sac 
three or four threads of silk. The fluid escapes through the punctures made 
by the needle. The seton must be allowed to remain until a sufficient degree 
of inflammation is developed to cure the disease. In the hydrocele of chil- 
dren I frequently employ, as already stated, a single thread, which I am care- 
ful to remove in twenty-four hours. In one case, where I employed the seton 
for the cure of hydrocele in an adult, it was followed by severe inflammation 
and suppuration, by which the life of the patient was for some time seriously 
jeopardized. 
Setons of silver wire instead of silk thread have been used, also catgut, 
but with no particular advantage. Allied in its operation to the seton was 
the tent, formed of lint or a piece of gum catheter, which was inserted into 
the sac after evacuating the fluid through a puncture. 
Caustic.-The treatment of hydrocele by a potent caustic, such as the 
caustic potash, was at one time advocated, especially by Mr. Cline. A 
slough was made by this agent over the scrotum as deep as the vaginal tunic. 
The inflammation excited in the latter membrane was followed by its con- 
traction and adhesion, or at least by such a change in the inner surface of 
the sac as arrested further secretion. 
Haematocele. 
Haamatocele is a collection of blood in the cavity of the tunica vaginalis. 
The source of the hemorrhage may be the vessels on the exterior of the 
vaginal sac, or those distributed to the testicle. The accumulation sometimes 
occurs suddenly, at other times gradually. 
Causes.-Hsematocele arises from degeneration of the blood-vessels of the 
testicle, in consequence of which theii* walls give way; from inflammatory 
attacks of the vaginal tunic; from violent muscular efforts exerted in the 
stooping position ; from external violence; and from wounds inflicted on 
some vessel or vessels of the tunica vaginalis or the testicle in tapping. 
The disease occasionally exists along with hydrocele. The blood after 
entering the vaginal tunic remains in a liquid state for some time, though 
eventually it undergoes considerable change, forming soft, broken-down 
clots, exhibiting a sponge-like texture, or possibly stratifications of decolor- 
ized fibrin. 
Symptoms.-Ilsematocele appears as an ovoidal or spherical tumor, largest 
below, heavy, firm in its consistence, opaque, and without fluctuation. The 
testicle bears the same relation to the blood in the sac as it does to the swell- 
ing in cases of hydrocele; that is, it is placed behind it. When haematocele 
follows an injury of the scrotum, the connective tissue of the latter becomes 
so infiltrated and discolored by sanguineous extravasation as to mask the 
presence of fluid in the vaginal sac. 
Diagnosis.-Haematocele may be distinguished from hydrocele by its 
greater weight, its imperfect fluctuation, the absence of translucency, and 
the suddenness with which it often appears. When any doubt remains, the 
grooved needle will remove all obscurity. 580 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
When the haamatocele occurs in connection with a hydrocele, the nature 
of the accident may be established by recalling the previous existence of an 
indolent scrotal swelling, and then considering the fact of its sudden and 
painful enlargement, not unfrequently attended by considerable constitutional 
disturbance. 
In old or chronic cases the tumor strongly simulates enlarged testicle, being 
hard, heavy, and inelastic; and as the thickening of the tissues and the 
solidity of the contents of the sac render it difficult to discover the testicle 
or to make sufficient pressure to excite the peculiar pain experienced on 
squeezing the gland, much uncertainty will exist from the similarity of the 
phenomena. An exploratory incision will furnish the only reliable solution 
of the difficulty. Castration has in several cases been done, under a mis- 
apprehension of the true nature of the malady. 
The structural changes which follow old hami- 
atoceles are quite marked. The tunica vaginalis 
is greatly thickened and rough, sometimes con- 
taining cretaceous deposits. The connective 
tissue external to the sac may also be thickened, 
and the testicle altered in shape, being flattened, 
the result of pressure. (Fig. 1341.) 
Treatment.-When the hsematocele occurs 
slowly and the collection of blood progresses, 
the proper plan is to place the patient in bed, 
support the scrotum, and surround it with cloths 
dipped in ice-water, or with ice alone, confined in 
an ice-bag or a bladder. The hemorrhage can 
in this way be arrested, after which the indica- 
tion is to favor the absorption of the blood, 
which process will be facilitated by strapping 
the scrotum and keeping it elevated. After the 
lapse of a few days the swelling will begin to 
disappear. Should the accumulation prove to 
be large, giving rise to much distention, pain, 
and tenderness, leeches should be applied over the cord, followed by a brisk 
cathartic and sufficient opium to allay suffering. When the blood remains 
fluid without being absorbed, the cure will be promoted by tapping the sac 
and drawing off its contents. Its re-accumulation will be the signal for a 
second operation. 
When the case is one of hydro-haematocele, no operation will be required 
at once, unless the swelling continues to enlarge, when the sac may be tapped, 
and, if necessary, this may be repeated from time to time, until all blood dis- 
appears from the fluid. After this, if desired, the hydrocele can be treated 
by tapping and injection. 
When the haematocele is large and progressing, whether with or without 
hydrocele, and when, in addition, there are much pain, heat, and scrotal infil- 
tration, indicating inflammatory action, a free longitudinal incision should be 
made through the scrotum down to the vaginal sac, which also must be laid 
open on a director or the finger, prolonging the division downward, so as to 
secure complete drainage. The parts are to be left open to heal by granulation, 
being merely dressed with some lint moistened with carbolated oil. Cases 
of old hasmatocele will occasionally be encountered in old persons, in which, 
from their size, the great thickness of the sac, and the unceasing irritation 
and pain experienced by the patient, it will be wiser to remove the testicle 
and the diseased vaginal tunic in their entirety than to resort to either 
incision or excision of the sac. 
Encysted hcematocele, in which the hemorrhage takes place into a sac or 
cyst formed over the epididymis or testicle, as in encysted hydrocele, is to 
be -treated on the same general plan as when the blood is poured into the 
common vaginal tunic. 
Fig. 1341. 
Thickening of the tunics of the testicle, 
induced by an old haematocele. INFLAMMATION OF THE TESTICLE. 
581 
Inflammation of the Testicle. 
Under the head of inflammation of the testicle are included epididymitis and 
orchitis. The two affections may exist separately or conjointly, and under 
two forms,-acute and chronic. The disease may have a common or a specific 
origin. 
Common orchitis occurs from both idiopathic and traumatic causes; fre- 
quently it is secondary to other diseases. 
Specific inflammation of the testicle depends for its existence on a peculiar 
state of the general system, such as is present in syphilis and tuberculosis. 
Epididymitis, or inflammation of the epididymis, sometimes called hernia 
humoralis,-very improperly,-is much more common than orchitis, or in- 
flammation of the secretory portion of the gland, a fact which is probably 
due to anatomical and functional peculiarities. The epididymis consists of a 
convoluted duct, its reduplications being held together by a considerable 
amount of connective tissue, and surrounded by a membrane which gives 
less support to its structure than that furnished to the glandular part of the 
organ by the tunica albuginea. 
There is a difference of opinion among surgical writers with reference to 
the side on which the disease exists with the greater frequency. Curling 
gives 138 cases of orchitis; the disease being on the right side in 78, on the 
left in 49, and in both glands in 11 instances. Bryant records a similar pro- 
portion in an analysis of 73 cases of the disease. On the other hand, Pro- 
fessor Sigmund, from much larger data, namely, 1342 cases of epididymitis, 
found only one-third of the number on the right side. As far as my own 
observation extends, the left side is most commonly affected. 
In consequence of the continuity of the subserous cellular tissue with the 
structure of the epididymis, the inflammation more frequently extends to the 
tunica vaginalis than when the glandular part of the organ is affected, and 
hence we find that hydrocele not unfrequently follows epididymitis. There 
is little tendency to suppuration whether the inflammation affects the testis 
or the epididymis. 
Causes.-Idiopathic inflammation of the testicle may arise from cold, 
though the occurrence is by no means common. The causes which usually 
give rise to the affection are an accidental injury, gonorrhoea, stricture of the 
urethra, the rude use of bougies, irritating injections into the urethra, cystitis, 
sexual excesses, prostatic disease, mumps, and a gouty, a rheumatic, or a 
syphilitic state of the general system. There is a form of orchitis described 
by Gosselin, and more particularly by M. Berrand, as frequently present in 
smallpox; it is termed variola orchitis. 
I have witnessed cases of the disease which appeared to be due to mias- 
matic causes, and which yielded readily to large doses of quinine. It is 
impossible to explain on anatomical grounds the frequent occurrence of or- 
chitis as a sequence of mumps. The testicle sometimes becomes inflamed and 
enlarged in very young children as a result of a contracted prepuce, or a stone 
in the bladder. 
Inflammation of the testicle occurs in the acute and in the chronic form. 
The acute variety is quite unusual in the glandular part of the organ, but 
exceedingly common in the epididymis ; and an attack of inflammation either 
in one or the other portion of the testicle predisposes to subsequent invasion. 
Occasionally both organs are simultaneously affected, or inflammation of one 
may be quickly succeeded by a similar state of the other testis. I shall speak 
first of epididymitis, and, secondly, of orchitis. 
Epididymitis generally occurs as a consequence of gonorrhoea, or from the 
use of bougies, or from any irritation located in the prostatic portion of the 
urethral canal. Its invasion is sudden; the testicle becomes swollen, tender, 
and painful, and not unfrequently the scrotum is found red and supersensitive, 
and even oedematous. Pressure made on the spermatic cord occasions con- 582 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
siderable uneasiness. Often the earliest symptoms experienced are tender- 
ness along the cord, and a hard, swollen state of the vas deferens. The 
pain, in virtue of the distribution of the nerves of the cord to the iliac re- 
gion and the groin, and their origin from the lumbar plexus, extends to 
the inguinal region and to the loins. The irritation is frequently reflected 
to the bladder, compelling the patient to pass water with unusual frequency. 
On examining the testicle, the swelling will be found to be confined to the 
posterior border of the gland, having an elongated, crescentic shape, and 
to be greatest at the lowest part of the epididymis or at the globus minor. 
The inflammation frequently extends to the tunica vaginalis, and is followed 
by serous transudation into its cavity, in which case the swelling becomes 
so diffused and general that it is impossible to trace the outlines of the 
epididymis. 
This extension of inflammation from the epididymis to the vaginal tunic, 
rather than to the glandular part of the organ, is most probably due to the 
continuity of the connective tissue of the two structures. The system 
strongly sympathizes in the local disturbance, as is seen in the elevated tem- 
perature and accelerated circulation which attend the inflammation. 
When epididymitis is secondary to gonorrhoea, it is thought that the inflam- 
mation reaches the testicle by travelling from the prostatic urethra along 
the ejaculatory duct and the vas deferens. This is not impossible; but I am 
disposed to believe that the nervous relation which subsists between the 
urethra and the epididymis is more actively concerned in causing the dis- 
ease ; in other words, that it is a transferred or reflex rather than a propa- 
gated process, similar in kind to what is frequently observed in sympathetic 
ophthalmia, rheumatism, or gout. Brodie, Sir Astley Cooper, and Curling 
favor the theory of inflammatory extension by continuity of tissue; but there 
are no facts to corroborate such a view. 
Generally the disease attains its height in the course of six or seven days, 
when the arterial excitement begins to abate; the pain subsides along with 
the swelling, and in the course of from twenty to twenty-five days, under 
judicious treatment, the disease has passed away. Indeed, the tendency is 
always to resolution, suppuration being exceedingly uncommon. Traces of 
the attack often remain for a long time after the affection has disappeared. 
The regular outline of the epididymis is interrupted by masses of lymph, 
which remain and give to the body an irregular surface, or occasion a marked 
hypertrophy of the globus minor. If the vaginal tunic has been involved 
in the disease, a certain degree of thickening of that membrane will also 
remain. 
Treatment.-The treatment of a case of acute epididymitis must be 
actively antiphlogistic. Rest in the recumbent position should be strictly 
enforced. If the inflammation has succeeded to a gonorrhoea, all urethral 
injections must be suspended. Often, indeed, the discharge from the urethra 
is suspended during the active inflammatory stage of the epididymitis, 
the latter acting as a derivative. Experience has shown the old practice, 
taught by Bloomfield, of restoring the urethritis in cases of gonorrhoeal 
epididymitis by the introduction of bougies into the canal, to be worse than 
useless. 
If the inflammatory symptoms are urgent, the hair may be shaved from 
over the cord at the external abdominal canal and a few leeches applied. 
They must not be placed on the scrotum, as their bites are followed by ex- 
tensive discoloration, from the extravasation of blood into the loose con- 
nective tissue of the part. With a view to drain the blood out of the testicle, 
the latter should be elevated, by placing beneath the scrotum a cushion, or 
by suspending it in a sling formed out of a handkerchief folded in a triangle 
and with its vertex and ends secured to another round the body. (Fig. 1342.) 
Previous to thus supporting the scrotum, the latter should be enveloped in a 
lotion of lead-water and laudanum, which can be renewed every three or four 
hours. The bowels are next to be cleared by an active cathartic. EPIDIDYMITIS. 
583 
If no amelioration of the disease is experienced after the lapse of thirty- 
six hours, the scrotum should be blistered by 
drawing longitudinally over its posterior surface 
a number of lines of nitrate of silver. In twenty- 
four hours each cauterized track will present 
a vesicated surface, the pain of which can be 
materially lessened by a hot-water dressing. 
Opiates will be required whenever the suffer- 
ing is sufficiently great to prevent sleep, and 
among this class of remedies none seem to 
answer a better purpose than Dover's powder, 
or the sulphate of morphia associated with ex- 
tract of hyoscyamus (morph, sulph., gr. I; ext. 
hyoscyami, gr. i), and administered at bedtime. 
If there is much febrile excitement, the neutral 
mixture, with a small amount of morphia and 
tartar emetic, can be given with advantage 
during the day. 
By the above treatment a mastery will gen- 
erally be early acquired over the disease, after 
which the pain and swelling gradually subside, 
leaving only the plastic infiltration to be re- 
moved. To accomplish this, the scrotum may 
be thoroughly painted with the compound solu- 
tion of iodine, or, what is preferable, compressed 
by the turns of a narrow elastic rubber roller, or by careful strapping with 
adhesive plaster, a practice introduced in 1835 by Fricke, of Hamburg, 
though Dr. Joseph Parrish, as early as 1800, had applied pressure by means 
of a narrow roller for a similar purpose. The application of adhesive strips 
is made as follows. The hair being removed, the testicle is drawn down into 
the bottom of the scrotum by grasping the latter at the cord between the 
thumb and index finger of one hand, and, while elongating the parts by 
traction, with the other hand apply a strip of plaster, about three-quarters 
of an inch in width and six or seven inches in length, around the scrotum a 
number of times, immediately above the fingers, with sufficient firmness to 
confine the testicle in the sac below. The remaining part 
of the scrotum is then covered in by strips of plaster par- 
tially overlapping one another, applied obliquely in a ver- 
tical direction from the neck of the purse, down over one 
side of its fundus and up over the other, the strips cross- 
ing above, so as to form a spica. (Fig. 1343.) The patient 
may possibly complain of some uneasiness for a time, in 
consequence of the pressure, but generally this gradually 
wears away. Should it, on the contrary, increase, the com- 
pression must be removed, as the time has not arrived 
ibr its use. 
The strapping ordinarily requires to be removed and 
replaced every day until the swelling and induration of 
the epididymis have disappeared. 
In case the induration still lingers, benefit will be derived 
from the internal use of the iodide of potassium, and also 
from alterative doses of mercury. If the patient is weak and pale, the iodide 
of iron, or quinine and iron, will be indicated. Generally any effusion into 
the vaginal tunic which may have existed disappears along with the indura- 
tion of the epididymis. When there is reason to suspect a miasmatic origin 
of the epididymitis, full doses of quinine must be given. 
In some instances the globus major and minor will remain permanently 
enlarged, unattended with any pain or special inconvenience. The effect of 
this hardness is often sufficient to occlude or obstruct the canal of the seminal 
Fig. 1342. 
Sling for the testicle. 
Fig. 1343. 
Adhesive strips applied 
to the testicle. 584 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
duct to a degree which will prevent the passage of the spermatozoa, thus 
rendering the patient sterile as long as the condition exists. As epididymitis 
is frequently excited by the reflected irritation of urethral stricture, the 
latter should be corrected as promptly as possible, otherwise the individual 
will be subject to recurring attacks of inflammation in this part of the 
testis. 
Acute Orchitis is not uncommon, and may arise from blows, kicks, forcible 
compression of the testes, mumps, tuberculosis, syphilis, rheumatism, and 
occasionally from an extension of inflammation from the epididymis when 
that body is affected. It is rarely produced by gonorrhoea. An undescended 
testicle is very prone to an acute inflammatory attack in the course of its 
transit from the inguinal canal to the scrotum. Orchitis may be unilateral 
or bilateral. The right gland is oftener affected than the left: when the 
disease occurs in children, as it occasionally does, it is, I believe, uniformly 
one-sided. 
Symptoms.-The testis, when inflamed, becomes rapidly swollen, though 
still retaining its natural oval form, with the exception of being somewhat 
more flattened. The gland feels heavy, and the pain, which is dull, is of a 
sickening nature, and radiates in the direction of the groin, hip, perineum, 
and loins. As the disease progresses, the scrotum becomes swollen, red, and 
tender, and all the parts so exceedingly sensitive that the patient keeps the 
limbs asunder, and, when standing, inclines forward, so as to avoid all press- 
ure on the testicle. When the orchitis is the result of causes connected with 
the late descent of the gland, it is accompanied by symptoms strongly simu- 
lating those of strangulated hernia, abdominal pains, nausea, vomiting, and 
constipation being present in the majority of cases. 
The symptomatic fever which accompanies the disease is quite marked, 
the heat of the body rising sometimes to 103°, with thirst, dry skin, head- 
ache, and scanty urine. As has been already stated, there is less tendency 
in orchitis for the inflammation to extend to the tunica vaginalis than in 
epididymitis, and consequently in the former disease fluid in the serous sac 
is not very common. 
As in epididymitis, the inflammation reaches its height in seven or eight 
days, gradually declining, until at the end of three weeks it has disappeared. 
Pathology.-Inflammation of the testis manifests little tendency to sup- 
puration, though this result is sometimes witnessed, the pus being either dis- 
seminated through the connective tissue supporting the seminiferous tubes, 
or inclosed in a cyst, the latter being formed by circumferential infiltration, 
as in ordinary abscess. When the purulent matter is diffused, the gland- 
structure is liable to become destroyed, leaving the tunica albuginea only an 
empty or flaccid bag. In aggravated cases, even this membrane undergoes 
ulceration or sloughing. Ordinarily, however, the inflammatory change 
observed in simple orchitis is a fibrinous and cell infiltration in the midst 
of the tubuli seminiferi, which causes the swelling and pain, and which disap- 
pears by absorption on the subsidence of the disease, though often leaving 
the testicle either softened or somewhat atrophied, and predisposed to subse- 
quent attacks on very slight provocation. 
Diagnosis.-Inflammation of the glandular part of the testicle may be 
distinguished from epididymitis by the form of the swelling, which in the 
first-named affection is ovoidal and flattened, while in the latter it is elon- 
gated, crescentic, and limited to the posterior border of the organ. 
The pain is unlike that of epididymitis, being more severe, dull, and sick- 
ening. The sense of great weight experienced in orchitis is also diagnostic. 
In epididymitis uneasiness is first felt in the cord, which is not the case 
in orchitis. Orchitis in its course is chronic; epididymitis, acute. Fluid in 
the vaginal tunic is uncommon in the former, very common in the latter 
disease. Impotence is liable to result from orchitis; rarely, if ever, from 
epididymitis. To these differential symptoms may be added dissimilarity of CHRONIC ORCHITIS. 
585 
origin, and effect on the constitution at large; orchitis,except when produced 
by traumatic causes, being generally the result of either mumps or constitu- 
tional conditions, such as tuberculosis, syphilis, variola, or rheumatism, and 
accompanied by disturbance of the general system ; while epididymitis is 
usually the result of disease of the urethra. 
Treatment.-Inflammation of the glandular portion of the testis is, at its 
commencement, managed very much as an epididymitis, namely, by rest in 
the recumbent position, and the application of a few leeches in the course of 
the cord, follow'ed by cold lotions of lead-water and laudanum. The scrotum 
should be elevated, and supported on a cushion or in a handkerchief sling. 
When there are much heat and pain, I have witnessed the most decided relief 
follow the use of ice, the most convenient mode of applying which is by break- 
ing it into small pieces, and, after putting it into a thin gum bag or a bladder, 
placing the latter beneath the scrotum. Sometimes cold increases instead of 
lessens the suffering, and when this is found to be the case it is well to be 
guided by the sensations of the patient,-to resort to hot fomentations of lau- 
danum and water, or, what will often answer better, to surround the parts with 
a flaxseed-meal poultice containing two or three leaves of tobacco. While 
it is desirable in all cases to keep the bowels regular, in a strong, robust pa- 
tient in whom the symptoms are decidedly acute the treatment may com- 
mence with an active purge. The pain and constitutional disturbance when 
severe must be moderated or controlled by opiates in combination with 
refrigerant mixtures, as the neutral mixture or spirit of nitre. When the 
violence of the attack has passed over, and the swelling and sensibility are 
on the wane, compression by adhesive strips, or by a narrow gum-elastic 
roller, can be employed with the same advantage as in epididymitis. Some 
of the French surgeons advise, in obstinate cases of orchitis, attended with 
fluid in the vaginal tunic and severe pain, to puncture the tunica vaginalis; 
and there can be no objection to the operation. The relief from pain which 
follows this procedure, by which the fluid contents of the serous sac are dis- 
charged and the pressure on the testicle is relieved, is very decided indeed, 
and in this consists its chief value. I cannot, however, claim as much for 
the operation of incising the tunica albuginea, which has been highly extolled 
by Vidal de Cassis. Such an incision is not without danger to the structure 
of the testis, from the escape of the seminiferous tubes through the opening 
made in the fibrous membrane. Demarquay, Salleron, and M. de Castelnau 
have each reported a number of cases in which the testicle was either entirely 
destroyed or seriously damaged in this way, which is a sufficient reason for 
the condemnation of the operation. 
Orchitis following mumps demands no special treatment other than rest, at- 
tention to the bowels, and an anodyne lotion. It disappears with the subsi- 
dence of the parotiditis. It is rarely followed by any atrophy of the testicle. 
Only in cases where the inflammatory action is severe will it be necessary to 
resort to active antiphlogistic measures. 
In rheumatic or in gouty orchitis, the ordinary antiphlogistic remedies avail 
very little. Iodide of potassium, salicylic acid, tincture of guaiac, and col- 
chicurn are best adapted for such cases. Blistering the scrotum may also be 
employed with advantage. 
Chronic Orchitis, though occasionally following acute inflammation of the 
gland, is generally symptomatic of a constitutional diathesis (syphilitic or 
tubercular). The disease is chiefly remarkable for the quiet manner in which 
it progresses. The testis is enlarged, hard, and flattened ; at first without any 
surface irregularity, and with little or no pain save in exceptional cases. 
Even when the testis is forcibly compressed or squeezed, there is an absence 
of the usual sickening sensation, particularly when the disease has existed 
for some time. Occasionally the inflammation extends to both the epi- 
didymis and the tunica vaginalis, and is followed by serous effusion into the 
cavity of the latter. 586 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Morbid Anatomy.-Allowed to progress without treatment, chronic 
orchitis from local causes will certainly cause irreparable structural alter- 
ations in the testis. The gland when laid open exhibits a yellow, cheesy 
deposit, sometimes appearing as a single central mass, at other times in 
several places through its substance, and which becomes so closely incor- 
porated with the glandular part of the testicle as to be inseparable from it. 
The seminiferous tubes are also filled with a yellowish-brown substance, 
rich in cells. In addition, there is an infiltration which interpenetrates the 
seminiferous tubules, is gradually developed into fibrous 
tissue, and, with the intertubular deposit, finally replaces 
the glandular components of the organ. (Fig. 1344.) 
In some instances suppuration follows; the tunica albu- 
ginea ulcerates, and the secretory structure of the gland 
is destroyed, leaving a withered and shapeless mass of 
connective tissue. 
Treatment.-In the form of orchitis under considera- 
tion, careful attention should be given to the improvement 
of the general health, which is often seriously at fault, and 
with this object in view the diet must be nutritious, the 
bowels carefully regulated, and tonics in combination with 
alteratives exhibited,-iodide of iron, iodide of mercury, 
and cod-liver oil being the most valuable. Inunction of the 
testicle with iodoform or mercurial ointment exerts a fa- 
vorable influence in removing the infiltration; and when 
these cease to do good, strapping may be used instead. If 
there is reason to suspect the existence of pus within the 
tunica albuginea, which may be determined by the use of 
the exploring needle, it should be evacuated as in an ordi- 
nary abscess. 
When the gland remains chronically enlarged, it has been 
suggested to expose the cord, and isolate and tie the sper- 
matic artery, thus cutting off the supply of blood and inducing atrophy. 
This operation was first executed by Harvey, the discoverer of the circula- 
tion, and has also been performed in two cases of sarcocele with success by 
Maunior, of Geneva. 
Fig. 1344. 
Section of a testicle 
exhibiting fibrous de- 
generation and showing 
two spaces filled with 
caseous matter. 
Syphilitic Orchitis, another variety of chronic inflammation, commences in 
so quiet and painless a manner that in many instances the disease has made 
considerable progress before the patient has discovered its existence. Fre- 
quently both testes are simultaneously affected. The gland soon becomes 
irregular, knotty, and heavy, and the serous or vaginal tunic frequently con- 
tains fluid. This affection, which is usually designated syphilitic sarcocele, is 
among the later or tertiary manifestations of the disease. It is occasionally 
seen in children shortly after birth, and is due, most probably, to inherited 
syphilis. 
Morbid Anatomy.-The pathological alterations which occur in syphilitic 
inflammation of the testes are usually confined to the body of the gland, and 
consist in a hyperplasia and condensation of its interstitial or connective 
tissue. This abundant new formation of connective tissue, unequally dis- 
tributed between the lobuli testis, is partly concerned in causing the irregu- 
larity of surface noticed in this variety of orchitis. There is also a large 
amount of a dense fibrogenous material irregularly deposited between the 
lobules, and also in different parts of the tunica albuginea, including the 
mediastinum testis, the presence of which, for the most part, gives rise to 
the nodular or knotty condition of the gland. 
In the midst of these undivided masses of connective tissue there lie dif- 
fused many cells in various stages of fatty degeneration, which impart a 
yellowish appearance to the morbid product, the whole constituting the 
gummy tumor so frequently observed in tertiary syphilis. The serous tunic TUBERCULAR OR STRUMOUS ORCHITIS. 
587 
is also the subject of inflammatory thickening, and its cavity generally con- 
tains a considerable amount of yellow serum. 
Should no attempt be made to interrupt the progress of the disease, the 
constant addition to, and the continued condensation and contraction of, the 
interlobular formation, will finally encroach so much on the seminiferous 
lobules as to cause wasting and destruction of their ducts, leaving only a 
mass of fibrous tissue instead, and necessarily destroying the function of the 
testicle. 
Should the testes in this condition, from any cause, traumatic or otherwise, 
experience an additional inflammatory attack, suppuration may follow, the 
pus collecting into little depots in the midst of the seminal lobules, or 
occupying the entire sac of the tunica albuginea, and destroying the gland- 
tissue by the pressure caused by the resistance of the fibrous coat. 
Diagnosis.-Attention to the following considerations will enable the prac- 
titioner to recognize with tolerable certainty a case of syphilitic orchitis, 
namely, the simultaneous invasion of both testicles; the absence of pain or 
any of the phenomena of acute inflammation; the extreme hardness and 
weight of the gland ; its irregular and knotty form ; the absence to the feel 
of all distinction between the testis and the epididymis, in advanced cases; 
and, finally, a history of pre-existing syphilis. 
Treatment.-In syphilitic orchitis, the fluid, when existing in any con- 
siderable quantity in the vaginal tunic, should be removed by tapping, 
after which the patient must be placed on the iodide of potassium, with or 
without mercury. Six to twelve grains of the former may be adminis- 
tered, three times a day, in any convenient menstruum. Or there may be 
added to each dose of the mixture one-sixteenth of a grain of the bichloride 
or the biniodide of mercury. In addition to the internal remedies, inunc- 
tion of the scrotum with mercurial ointment, either alone or associated with 
iodoform, will conduce to the cure. In good constitutions, mercury alone, 
in small alterative doses, will exert a powerful influence in determining the 
absorption of the fibrous and gummy deposits. For this purpose one-fourth 
of a grain of calomel may be given four times a day, until a diminution 
of the enlargement is noticed, taking care not to push the drug to the 
extent of salivation. Should the mercurial disturb the bowels, it can be 
combined with a very small quantity of opium. The orchitis which is 
sometimes witnessed in very young children is generally the result of in- 
herited syphilis, and yields to both the iodide of potassium and the mercurial 
treatment. 
Tubercular or Strumous Orchitis is not an uncommon affection. It is met 
with at all ages, though commonly between the ages of twenty-five and 
thirty-five, and involves both the body of the testis and the. epididymis, 
the latter generally being first affected. Like syphilitic orchitis, it is often 
bilateral. 
Symptoms.-The commencement of tubercular or strumous inflammation 
of the testicle is not announced by pain or any other sign calculated to at- 
tract at an early period the notice of the patient. The gland becomes hard, 
knotty, and irregular in form, and the same condition not unfrequently may 
be detected in the vas deferens and seminal vesicles. Compression of the 
gland does not cause the peculiar sensation produced by pressure on the 
sound organ. The skin over the testicle remains unaltered in appearance 
and moves freely over the gland, unless suppuration takes place, when it 
becomes cedematous, adherent to the tunica vaginalis and tunica albuginea, 
and finally ulcerates, the pus and glandular tissue of the organ being dis- 
charged through the opening. There is in these cases of tubercular orchitis 
a strong tendency to the formation of abscesses, which after discharging 
their purulent contents leave fistulous openings which remain sometimes 
for years exhibiting no disposition to heal. When both testes are involved, 
the sexual appetite is very much lessened, and may be entirely lost. Not 588 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
unfrequently the disease of the testicle has been preceded by tuberculosis of 
the lungs. 
Morbid Anatomy.-The structural changes observed in tubercular orchitis 
differ considerably from those which belong to syphilitic sarcocele. The 
general appearance presented is that of round or irregular cheesy masses 
or nodules. These masses in some places are distinct or isolated from one 
another, and in other parts of the organ are blended. Externally they are 
quite firm, even elastic; but, their vitality being low, they are prone to con- 
traction, softening, and suppuration. In tracing the location of the new 
formation, and its relation to the seminiferous tubules, there appears to be a 
cell-infiltration occupying the peri-tubular lymph-spaces, partly undergoing a 
fibrous transformation, and constituting the true nodular tubercles. While 
these changes are going on in the interlobular spaces, the interior of the semi- 
niferous tubes of both the epididymis and the testis are not exempted from 
the morbid action. They become distended by an accumulation of prolifer- 
ating endothelium, granular matter, and a yellowish-white cheesy material, 
which infiltrates and disorganizes their walls, until finally all traces of secre- 
tory and conducting structure disappear, and both the testis and the epididy- 
mis are converted into a sac filled with this peculiar scrofulous material. This 
deposit has been shown by Dr. Clark to undergo different changes, one part, 
particularly that near the centre, consisting chiefly of granular material, 
while nearer the circumference cell-forms prevail, and throughout the gland 
are to be seen particles of fat and crystals of the triple phosphate of lime. 
It is not improbable that these crystals are derived from decomposition of the 
seminal secretion. There are, therefore, in the form of tissue-degeneration 
under consideration both an extra-tubular and an intra-tubular deposit, the 
first located in the inter-tubular connective tissue, the second within the 
tubes of the testicle. By those who make a distinction between tuberculosis 
and scrofula these two depositions have been regarded, without, I think, 
sufficient reason, as distinct kinds of morbid material, the former being tuber- 
cular and the latter scrofulous in its nature. Both are equally destructive to 
the gland, the former causing the absorption of the walls of the seminiferous 
tubes by external compression, and the latter by infiltration, or, as the so- 
called tubercular and scrofulous depositions exist at the same time, the 
disorganization is the conjoined effect of both processes. 
In certain constitutions the disease is not limited to the tubular structure 
of the testis and epididymis, but may extend through the entire length of 
the vas deferens, seminal vesicles, ureters, and kidneys. 
Terminations.-The termination of a case of tubercular or strumous tes- 
ticle is not always the same. Frequently the serous and fibrous coats of the 
testicle become adherent to the scrotum through adhesive inflammation. 
While the deposit within the tunica albuginea is being gradually replaced by 
a collection of pus, ulceration follows, giving rise to one or more fistulous 
openings, which continue to discharge indefinitely, or a fungous growth may 
protrude through one of the sinuses. This constitutes the "hernia testis." 
Again, when the disease affects principally the epididymis, and is followed 
by ulceration of the scrotum and the tunica vaginalis, the body of the tes- 
ticle, with its fibrous coat unbroken, may prolapse through the external 
opening. 
Under favorable circumstances the morbid deposit may undergo changes 
which will leave the testicle without serious damage. These retrograde 
metamorphoses may result, when the formation has been of limited extent, 
in its complete removal by absorption, or, after its more liquid portions have 
been absorbed, in a fatty degeneration of the residue, by which it is converted 
into a dry, cretaceous mass. This, like any other foreign substance, may 
become encysted in a wall of lymph, and repose harmlessly in the testicle, 
giving the patient no future trouble. 
Diagnosis.-Tubercular and strumous orchitis may generally be distin- 
guished from syphilitic orchitis by the following considerations: FUNGUS OF THE TESTICLE. 
589 
SYPHILITIC ORCHITIS. 
The body of testis first affected. 
May occur at any age after puberty. 
Uniformly hard; not markedly irregular, ex- 
cept at first. 
Little tendency to suppuration, rather to fibroid 
degeneration. 
Fistulae uncommon. 
Fungous outgrowths rare. 
Health unaffected. 
Other syphilitic manifestations. 
TUBERCULAR AND STRUMOUS ORCHITIS. 
Affects primarily some part of the epididymis. 
Not often seen after thirty. 
Knotty, irregular, with intermediate soft points. 
Softening and suppuration common. 
Fistulas common. 
Fungous outgrowths common. 
Health generally impaired. 
Tubercular diathesis, other organs being in- 
volved. 
Treatment.-The treatment of chronic orchitis consists in improving the 
general health by good diet and by moderate exercise in the open air. Inter- 
nally, iodide of potassium, iodide of iron, and cod-liver oil are the most potent 
remedies. Locally, an ointment of iodoform or of the iodide of lead will 
favor the work of absorption. When suppuration occurs, the abscesses, if 
well matured, should be lanced. If they are allowed to open themselves, 
there will be a greater tendency to the formation of others. 
The ulcerated openings require to be touched with nitrate of silver, and, 
when the discharge is not profuse, the scrotum may be advantageously 
strapped. Under this treatment the fistulte occasionally heal and the patient 
recovers. 
Excision of the diseased testicle should be practiced only as a last resort 
and when the surgeon has indubitable evidence of the utter and hopeless dis- 
organization of the organ. In more than one instance I have seen recovery 
take place after the gland had been doomed to the knife. 
Fungus of the Testicle exists under two forms : first, as an ash-colored or 
yellowish mass protruding through an opening in the scrotum (Fig. 1345), 
made up of seminiferous tubes and granulation tissue, and from which is 
discharged a thin, ichorous matter; secondly, in a growth of granula- 
tions from an exposed portion of the tunica vaginalis and tunica albuginea; 
in both instances the result of disease of the testicle, (Fig. 1346.) At one 
Fig. 1345. 
Fig. 1346. 
Fungus, or " hernia testis." 
Fungous granulation from the tunica albuginea of the testicle. 
time they were regarded as malignant, but their benign character was recog- 
nized by Lawrence* many years ago, to whom also we are indebted for a 
rational plan of treating the disease. The fact of their being often non- 
malignant has originated for these growths the name " benign fungus." 
The absence of any very unpleasant odor, the peculiar pain of the testicle 
produced by pressure on the granulatory mass, and the absence of any 
tendency to hemorrhage, are sufficient to distinguish benign fungus from 
malignant disease. 
The plan of treatment generally adopted, and which answers well in most 
cases, consists in cauterizing the surface of the fungus with nitrate of silver, 
placing compresses of lint on its surface, and then applying pressure by ad- 
* Edinburgh Medical and Surgical Journal, 1803. 590 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
hesive plaster. This dressing is to be renewed from day to day until the 
growth has been reduced to a level with the integument, when the edges of 
the opening in the scrotum are to be gradually brought towards each other 
by adhesive strips, until finally they are closed over the granulating mass. 
Syme in two or three instances attained the same result by loosening up and 
paring the edges of the opening, and uniting them over the fungus by sutures. 
Encephaloid Disease of the Testicle is the form of cancer which usually 
occurs in the testicle. This affection is peculiar to no age. Of the 51 cases 
collected by Mr. Ludlow, 5 were in children under five years of age; 1 in a 
boy; 11 in persons between twenty and thirty; 22 between thirty and forty; 
6 between forty and fifty; and G between fifty and seventy. 
Of 16 cases analyzed by Mr. Bryant, 1 was under five years of age; 1 be- 
tween fifteen and twenty; 5 between twenty and thirty; 5 between thirty 
and forty; 2 between forty and fifty; and 2 between fifty and seventy. 
Malignant disease of the testicle is invariably unilateral. In the cases 
which have come under my own observation, the right gland has been most 
frequently affected. An undescended testicle is liable to become the subject 
of cancer. 
Symptoms.-Encephaloid disease of the testicle commences by the deposit in 
the seminiferous tubes of one or more small nodules, which, rapidly enlarging, 
soon involve both the body of the testis and the epididymis, without mani- 
festing any signs of inflammation. The swelling is at first smooth and hard, 
a condition which it retains as long as the structure of the tunica albuginea 
is not materially injured. When, however, the fibrous coat begins to yield, 
the part becomes soft and almost fluctuating. The pain is rarely shooting 
or lancinating, generally a dull ache. Press- 
ure occasions none of the sensations ex- 
perienced when the sound gland is squeezed. 
After a time the tunica albuginea gives way 
in one or more places, allowing the growth 
to protrude, and giving an irregular surface 
to the tumor. At several points soft, fluctu- 
ating swellings or cysts appear; the veins 
over the distended scrotum become dilated, 
the cord thickened, and, finally, the lumbar 
glands enlarged. The tumor in many cases 
acquires an enormous bulk, equal in size to 
a cocoanut or a child's head. When ulcera- 
tion takes place, the tumor protrudes in the 
form of a horrid, bleeding fungus (Fig. 1347), 
from which is discharged a stinking sanies. 
The general health rapidly fails, the face 
becomes sallow, and the body emaciates, the 
disease terminating fatally in from eight to 
twenty months. 
Diagnosis.-Encephaloid disease of the testicle may be confounded with 
syphilitic or tubercular orchitis. The characteristics of the three diseases 
are contrasted below: 
Fig. 1347. 
Encephaloid fungus. 
ENCEPHALOID ORCHITIS. 
No history of malignant an- 
tecedents. 
Begins in the body of the 
organ. 
Rapid in its course. 
Skin of the scrotum finally 
involved. 
Ulceration and fungus com- 
mon. 
SYPHILITIC ORCHITIS. 
Syphilitic history. 
Slow in its progress. 
Skin rarely involved. 
Ulceration or suppuration 
rare. 
TUBERCULAR ORCHITIS. 
Tubercular history. 
Begins in the epididymis. 
Slow in its progress. 
Skin involved only just before 
formation of abscess. 
Suppuration common. ENCEPHALOID DISEASE OF THE TESTICLE. 
591 
ENCEPHALOID ORCHITIS. 
Pain severe, lancinating in 
an advanced stage. 
Soft and fluctuating. 
Net-work of large veins over 
surface of tumor. 
Attains great size. 
Painless on pressure. 
Generally one testicle affected. 
Fungus always present in ad- 
vanced stages. 
Bleeds freely, very rapid 
growth, offensive odor. 
Rarely extends beyond twenty 
months. 
Fatal. 
Inguinal and lumbar glands, 
skin, and cord affected. 
SYPHILITIC ORCHITIS. 
Weight without pain. 
Hard. 
Not so. 
Moderate size. 
Painless on pressure. 
Often both. 
Fungus rare. 
Many years. 
Curable. 
Bubo may be present. 
TUBERCULAR ORCHITIS. 
Little pain. 
At first hard. 
Not so. 
Moderate size. 
Painful on pressure. 
Often both. 
Fungus common. 
Several years. 
Generally incurable. 
No inflammation of the in- 
guinal or lumbar glands. 
Morbid Anatomy.-The infiltration is found affecting the body of the 
testicle, the epididymis, the vas deferens, and the pelvic lymphatic glands. 
As this cell-infiltration is irregularly disseminated, the softened, white, pul- 
taceous material which follows is found in patches instead of being regu- 
larly distributed through the structure of the gland. Histologically, the 
source of the cells which confer the specific or malignant character on the 
growth is the epithelium of the seminiferous tubules, the proliferation of which 
constitutes the primary stage of the disease, preceding, in order of time, the 
intertubular infiltration. So far as can be determined by a simple inspection 
of the morbid growth by the unaided eye, there is nothing by which it can 
be distinguished from sarcoma. The fungous growth which protrudes after 
the tunica albuginea gives way consists very largely of an exceedingly fine 
and complex net-work of vessels, developed from those occupying the inter- 
tubular connective tissue of the gland. 
Treatment.-Excision of an encephaloid testicle tends to prolong life, but 
is powerless to cure, the disease uniformly returning. The operation, how- 
ever, should be limited to the latter stages of the disease, when the tumor is 
about to ulcerate, or when the fungous growth is already existing. By the 
use of the knife under these circumstances the foul mass of diseased granula- 
tions with its unpleasant odor is removed for a time and the hemorrhage 
prevented. 
Opiates to relieve pain and procure rest may be administered, together 
with tonics and a nutritious diet, and at the same time the parts should be 
kept in a cleanly state, when ulceration has occurred, by frequent ablutions 
with a solution of the permanganate of potash, bromo-cbloralum, or nitrate 
of lead. 
The results of operations performed for cancer of the testicle are not of a 
very encouraging nature. Of 36 cases reported, 7 died,-3 within one week, 
2 within six weeks, and 2 within three months.* And yet there are quite 
a number of cases recorded in which life was doubtless prolonged by the 
operation of castration, and in some of which the disease was possibly 
cured. 
Curling has collected 9 cases in which the patients were living after the 
excision of the testicle for cancer; 1, fifteen years; 1, five years; 1, seven 
years; 1, twelve years; 1, nine years; and 4, five, four, three, and two years 
respectively. The period at which the disease returns after the excision has 
been recorded by Mr. H. Ludlow in 23 cases. In 13 of these there was a 
recurrence of the cancer at various periods from six to eighteen months. 
In 5 the patient enjoyed exemption for two years; in 4, for three years; and 
in 1, for ten years. 
With the exception of melanosis, and that rarely, the other varieties of 
cancer are never met with in the testicle. 
* Medical Journal and Gazette, vol. xix. 592 
INJURIES AND DISEASES OF THE GENITOURINARY ORGANS. 
Sarcoma.-This affection is not so common a§ encepbaloid disease. Its oc- 
currence is restricted to early life, rarely being seen after the twenty-seventh 
year or under the fifteenth. It is remarkable for combining in itself all the 
histological elements peculiar to the different species of sarcomata ; and not 
only so, but these growths are singularly associated with cyst, cartilage, 
fibrous, mucous, adipose, and muscular tissue. 
Symptoms.-Sarcoma of the testicle is generally unilateral, and begins in 
the body of the gland, though it may subsequently extend to the epididymis. 
The progress of the tumor is slow and unattended with pain, though, after 
it has attained considerable bulk, a sense of dragging and uneasiness is expe- 
rienced from the weight of the growth. 
For some time the testicle preserves its oval form and smooth surface, and 
may readily be distinguished from the epididymis. This distinction is finally 
lost by the extension of the disease, and the smooth surface of the swelling 
is replaced by irregularities frequently due to the formation of cysts. 
Notwithstanding the tumor may attain great magnitude, the skin remains 
movable over its surface, the superficial veins are unchanged, and ulceration 
does not occur. Should the disease not undergo an encepbaloid change (one 
to which it is strongly predisposed), it may continue for several years with- 
out materially affecting the general health of the patient. 
Diagnosis.-Sarcoma may readily be confounded with encepbaloid disease 
of the testicle, and, as has been stated, the two are frequently found existing 
together. In typical cases of the two affections, however, there are certain 
differences which will serve to establish the distinction. 
SARCOMA. 
Limited to early life. 
Health remains unaffected. 
Slow growth. 
Does not ulcerate. 
No fungous growth. 
Painless. 
Skin not implicated. 
Fluid in the vaginal tunic rare. 
Involves the epididymis late. 
ENCEPHALOID DISEASE. 
May occur at all periods of life. 
Health suffers, especially when fungus appears. 
Rapid growth. 
Ulcerates. 
Fungous growth. 
Painful. 
Skin implicated. 
Fluid in the vaginal tunic common. 
Involves the epididymis early. 
Histoid Elements.-In pure 
cases of sarcoma of the testicle 
there exist a vast number of 
both round and spindle cells, 
with a fibrillated, intercellular 
net-work. (Fig. 1348.) 
Prognosis.-In consequence 
of the very common interming- 
ling of both encepbaloid and sar- 
comatous elements, the prog- 
nosis in these tumors of the 
testicle is extremely unfavorable 
either without or with an opera- 
tion. 
Notwithstanding the frequent 
recurrence of sarcoma after ex- 
cision, it will occasionally hap- 
pen that the patient will enjoy 
immunity from the disease for 
one or even two years; and with 
this prospect in view, together 
with the peace of mind which 
follows the removal of an affec- 
tion which is daily a source of 
anxiety, I always advise an operation unless the tumor manifests a quiescent 
Fig. 1348. 
Microscopic view of a sarcoma, of the testicle. The upper 
portion of the cut shows the peculiar wall-less blood-vessels 
lying between round embryonic cells; in the lower portion is 
seen the atrophied glandular structure with two seminiferous 
ducts in transverse section. CYSTIC DISEASE OF THE TESTICLE. 
593 
disposition. I have many times performed this operation, and have found 
no reason to modify this opinion. 
Lymphadenoma of the Testicle is a rare variety of the disease which 
strongly resembles medullary cancer. Its chief difference from ordinary sar- 
coma consists in the greater number of its cell-forms and the very soft con- 
sistence of the growth, besides its association with manifestations of the 
disease in other organs. In cases of this nature both testicles are often 
implicated at the same time. 
Cystic Disease of the Testicle is found as an independent affection, and 
also associated with encephaloid, sarcomatous, and enchondromatous condi- 
tions of the organ. It is the "hydrated testicle" of Sir Astley Cooper. The 
disease commonly begins between twenty and forty, though it has been ob- 
served at the age of two years. 
When existing in an uncomplicated state, cystocele commences in the rete 
testis, afterwards extending to the body of the testis and the epididymis; is 
a painless and slowly-progressing swelling, which finally extends to the 
epididymis; is oval in shape, smooth and elastic to the feel, and is generally 
attended with fluctuation. The tumor often grows to a very great size. 
The cysts vary in number and in size. Many are not larger than a pin's 
head, while others would readily receive a pigeon's egg. Some are simple 
and others are compound and contain a fluid of different degrees of consist- 
ence, in some instances as thin and almost as colorless as water, and in other 
cases ropy or gelatinous, and containing diverse substances, as dark yellow, 
globular bodies, a whitish material, blood-corpuscles, fat, and cholesterin. 
These cysts are surrounded by a more or less dense wall of connective tissue 
(Fig. 1349), and lined with a tessellated epithelium. The origin of these is 
believed by Curling and Virchow to be the 
tubes of the rete testis, while Klebs and 
Kolliker go further, regarding these cavities 
as the result of an active cell-proliferation 
within the seminiferous tubules, giving rise 
to their dilatation, or, in other words, an 
adenoma. 
Diagnosis.-In advanced cases of cystic 
disease the tumor may readily be mistaken 
for hydrocele, or hsematocele, or encephaloid 
cancer. From hydrocele it may be dis- 
tinguished by the greater weight of the 
tumor, by the absence of translucency, and 
by its ovoid al form, all of which are char- 
acteristics of cystoma. In hsematocele the 
same opacity, form, and weight exist as in 
cystoma, and consequently the differential 
diagnosis is more difficult; but the obscurity 
will be cleared up by considering that no 
pain is experienced when the testicle is com- 
pressed in cystic disease, and that in the 
latter affection there is, in its advanced 
stage, an enlargement of the veins over the 
surface of the scrotum. A still more satis- 
factory solution of all doubt will be obtained 
by introducing a small trocar into the swell- 
ing, which, in hsematocele, will be followed 
by the discharge of blood and a diminution of the size of the tumor. In 
malignant disease there may also be some blood discharged on puncturing 
the tumor, but it will be more florid than that obtained from hsematocele, 
and the size of the growth will not be lessened. There is, moreover, in 
Fig. 1349. 
Cystic disease of the testicle.-From a prep- 
aration in the museum of the University of 
Pennsylvania. 
vol. ii.-38 594 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
malignant disease of the testicle, some derangement of the general health, a 
cachexia, together with enlargement of the retro-peritoneal and often of the 
inguinal glands. 
Treatment.-Neither local nor constitutional treatment will exert any 
influence in arresting the growth of the disease. Nothing short of excision 
of the testicle will answer; and then, if there is no malignant element in 
conjunction with the cystic disease, there will be a reasonable ground for 
hope that the affection will not return. 
Of sixteen cases in which the testicle was removed on account of cystic 
sarcoma, all recovered from the operation,* and in five cases of my own there 
were no deaths. As all of these patients passed out of my observation 
except one, I was unable to follow their subsequent history. In the one 
referred to, the disease returned in a few months and terminated fatally. 
Enchondroma is often found associated both with cystoma and with sar- 
coma. When present in cystoma, the cartilage-usually hyaline-exists 
in small, hard nodules lying in the midst of the intertubular connective 
tissue, and may attain considerable magnitude. When associated with 
malignant deposit in the testicle, the cartilage lies in the midst of the en- 
cephaloid material, but separated from it by a surrounding wall or capsule 
of fibrous tissue. The development of the cartilage in these cases of enchon- 
droma takes place in the intertubular connective tissue of the testis. 
Enchondroma may be recognized by its extreme density, elasticity, and 
weight, its slow progress, and the absence of any unusual sensibility It 
may continue for years, when uncomplicated, without occasioning any other 
inconvenience than that arising from its weight; but should its presence 
invite a sarcomatous formation,-a very probable occurrence,-the whole 
aspect of the case will be changed, in consequence of the great activity of 
the disease. 
Treatment.-Early excision of the testicle should always be practiced, 
even when the tumor is believed to be wholly cartilaginous and passive. 
When this rule is adhered to, we may succeed in getting rid of the disease 
before the more serious element of malignancy is developed. 
Myoma is among the rarest of the tumors of the testicle, and is perhaps 
in most instances associated with sarcoma or cancer. 
It has been described by Rokitansky and Billroth. It consists of both 
smooth and striated muscular fibres. Rindfleisch examined a growth of this 
nature in which there were a large number of nerves running among the 
muscular fibres. The diagnosis of these tumors is necessarily attended with 
much obscurity. 
Calcareous Depositions in the testicle are occasionally seen. They do not 
partake of the nature of bone, but are a mere aggregation of granules of 
earthy salts devoid of animal matter. The calcification sometimes assumes 
quite an orderly form, being disposed in regularly superimposed layers; at 
other times there is an entire absence of anything like order, the deposit 
being a shapeless mass. 
The seat of these degenerations may be in the tunica albuginea or in the 
vaginal tunic in old hydroceles, in the testis, and in the globus minor of the 
epididymis. Frequently calcareous matter is present in enchondroma and 
in cystic and fibrous disease of the testicle. Curling believes these earthy 
deposits to be frequently due to degenerations in previously existing tuber- 
cular matter. Such formations are not unfrequently discovered at the bottom 
of sinuses which remain after tubercular abscess, and through which they 
have been discharged; indeed, they may serve to perpetuate a fistula of the 
scrotum. The presence of these earthy masses may be recognized by their 
extreme hardness and weight. 
* Medical Times and Gazette, vol. xi. p. 395. IRRITABLE TESTICLE. 
595 
The treatment of calcareous degeneration must be determined by the nature 
of the neoplasms with which it is associated. 
Fibroma of the Testicle is exceedingly uncommon. There are cases in which, 
after inflammatory and other changes in the testicle and epididymis, a dense 
mass of condensed connective tissue will remain, forming quite a noticeable 
nodule; but these enlargements can scarcely be said to assume the impor- 
tance of tumors. Cruveilhier has, however, furnished an example of a true 
fibroma, one before which the glandular tissue of the testis had disappeared, 
and which in most respects resembled the ordinary uterine fibroid in the 
arrangement of its fibres. Fibro-plastic or recurring fibroid neoplasms of 
the testicle have been described by Lebert and Hovard, which, after their 
removal, soon returned, and proved fatal. 
Irritahle Testicle.-There are two painful conditions of the testicle which 
are frequently met with, neither of which is necessarily the result of any 
local disease in the gland. 
These are the hypersesthetic or irritable, and the neuralgic. The first is 
characterized by a supersensitive state of the testicles on handling them, often 
aggravated by walking or by riding on horseback. The undue sensibility 
is not always limited to the testes, but frequently extends to the cord, and 
may be attended with such excessive irritability of the genital organs as to 
occasion great mental distress and despondency. This condition may arise 
under circumstances diametrically opposite, namely, in young persons ad- 
dicted to masturbation, or who are given to excessive sexual indulgence, or 
who suffer from frequent nocturnal emissions; and again in those who, not- 
withstanding strong and frequent sexual excitement, have resolutely refused 
to gratify their animal desires. In the first instance the nervous endowments 
of the genital organs have been exhausted; in the second there is a plethora 
of the sexual apparatus. The same kind of irritability is not unfrequently 
witnessed at the period of adolescence, when the supremacy of the repro- 
ductive organs is about to be asserted, and also occasionally in persons with 
varicocele. 
In cases coming under the first category the symptoms of indigestion, as 
feeble appetite, flatulence, constipation, gastric distention, lumbar pains, and 
great depression of spirits, are prominently present; in those belonging to 
the second class headache or fullness of the head is complained of. 
Treatment.-In cases of hypersesthesia, the habits of the patient must be 
carefully inquired into. If he is addicted to self-abuse or sexual excess of any 
kind, the practice must be relinquished, and in order to improve the general 
health and strength it will be necessary to enforce the shower-bath, of such 
temperature as will induce no chill, to administer tonics of iron and strych- 
nine, and to insist on an out-door life. The testicles should be douched two or 
three times a day, and supported in a properly-fitting suspensory bag. When 
the patient is harassed by seminal emissions, it may be necessary to cauterize 
the prostatic portion of the urethra. 
I have had patients laboring under this morbid irritability of the testicle 
who have been solicitous to have the gland removed, with a view to escape 
from the suffering. 
Castration, however, is never justifiable under such circumstances, as with 
judicious management all these symptoms will disappear. When the irrita- 
bility occurs in persons who lead continent lives, the use of an occasional 
laxative, of bromide of potassium, and active exercise carried to the extent 
of fatigue, will usually afford relief. 
In cases of this kind marriage proves the most effectual remedy. 
Neuralgia of the Testicle, a painful condition of the spermatic nerves, is 
almost invariably confined to one side, and is met with at all periods of life 
after puberty. In my own experience the left testicle has been more fre- 596 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
quently the subject of the affection than the right. The pain is generally of 
a lancinating character, shooting both up and down the cord, and is often 
accompanied by violent retraction of the testis. 
The attacks come on usually at irregular intervals, though sometimes they 
assume a marked periodicity. During the paroxysms the suffering is often 
exceedingly severe, so that the patient may lose all control over his feelings. 
After the attack is over, the testicle may return to its natural condition, 
though it is left in an extremely sensitive state, so that the mere pressure of 
the clothing against the scrotum becomes intolerable. 
In a few instances I have seen the epididymis, especially the globus major, 
become swollen during the paroxysm, gradually resuming its normal size 
with the decline of the pain; and in one case of extraordinary severity, and 
of prolonged duration, the epididymis of the unaffected side became con- 
siderably enlarged, though not very tender. 
Repeated attacks of spermatic neuralgia tend to produce a subacute epi- 
didymitis, with more or less permanent induration. 
Causes.-The causes of neuralgia of the testicle are often remotely situated 
from the glands, and among these may be mentioned renal or vesical calculi, 
the passage of a stone or of gravel along the ureter, urethral stricture, cys- 
titis, and disease of the spinal marrow and its membranes. The disorder 
may be associated with varicocele, orchitis, and epididymitis; it may also be 
excited by causes of a more general nature, as gout, rheumatism, disorder of 
the digestive apparatus, anaemia, excessive venery, and miasma. 
Treatment.-The successful treatment of a case of neuralgia of the testicle 
must be based on a just appreciation of the cause. 
When the paroxysm is excited in consequence of the passage of a calculus 
along the ureter, it can be relieved only by the use of such measures as will 
favor the transit of the concretion to the bladder, as hot hip-baths, and ano- 
dynes administered by the mouth, by the rectum, or subcutaneously. When 
caused by the irritation of crystalline substances formed in the urine before 
it leaves the kidney, which can be determined only by a microscopic ex- 
amination of the secretion, the treatment must be guided by the chemical 
constitution of the crystalline compounds. 
If a stone in the bladder exists, its removal can alone secure exemption 
from the neuralgia. The pressure of varicose veins will suggest the necessity 
of a suspensory bandage. When a gouty or rheumatic state of the general 
system is believed to underlie the affection, this condition must be corrected 
by purgatives, iodide of potassium, and colchicum. Should there exist de- 
rangement of the organs of digestion, improvement can be expected only 
when by laxatives, alteratives, and tonics this derangement has been remedied. 
If the sexual appetite has had unlimited indulgence, the patient must put 
a check on his passions; and when the attacks have been of a periodical 
character, indicating a miasmatic origin, quinine in full doses, or quinine 
with arsenic and piperine, will generally arrest the paroxysms. Occasionally, 
it is said, the painful condition of the testicle can be referred to undue activity 
of the secretory function of the testis, occasioning a seminal congestion. If 
this were the case, both testicles should suffer in common, unless it can be 
shown that unilateral seminal engorgement may occur. I have never seen 
any case which could be properly referred to such a cause. 
Excessive and ungratified sexual excitement will sometimes be followed 
by neuralgic pain ; and for such a condition bromide of potassium can be 
administered with great benefit. 
There are, however, cases in which it is impossible to discover the true 
causation, and in which our remedies must be directed to the relief of the 
symptoms as they appear. For this purpose opium, in some of its forms, 
hyoscyamus, belladonna, and turpentine will be found to yield the best results; 
and externally, cauterization of the scrotum with nitrate of silver, lotions of 
laudanum, and poultices of flaxseed-meal and tobacco leaves. 
Should.a case prove utterly incorrigible under all treatment, and its severity ATROPHY OF THE TESTICLE. 
597 
be such as to render the life of the patient constantly miserable, the question 
of castration will naturally come up for consideration. 
The operation has been frequently performed for the cure of neuralgia of 
the testicle, sometimes with success, but often without any benefit. 
This measure may be resorted to when the usual remedies have been 
employed without effecting relief; when the paroxysms are very frequent, 
the pain extremely severe, and the general health beginning to give way; 
and, last and most important, when there is sufficient reason to believe that 
the cause is located in the testicle, or in the cord below the external abdominal ring. 
Whenever the cause is general, or remote from the testicle, castration is 
utterly valueless. 
Hypertrophy.-Except in marked cases it is difficult to recognize hyper- 
trophy of the testicle, inasmuch as we have no fixed size or weight of the 
normal gland with which to make our comparisons. The testicles are 
rarely found to be of the same size, the left being usually larger than the 
right; or if one appears to be under size, the other by its increased bulk com- 
pensates for the deficiency. The size of the testicles varies so much in differ- 
ent persons that I doubt if any practical standard exists. Meckel fixed the 
weight at four drachms, which Curling thinks too low an estimate. Prob- 
ably a testicle weighing six or seven drachms might be considered hyper- 
trophied; that is, containing an unusual amount of gland-tissue. Such 
increased size, however, possesses little surgical interest, as it is no more a 
morbid condition than an unusually-developed muscle or mammary gland, 
and cannot be productive of disease. 
Atrophy.-There is a form of atrophy of the testicle which is in entire 
accordance with what is observed in other structures of aged persons, and 
which may be termed senile atrophy. 
This is essentially the result of fatty degeneration of the tubuli seminiferi, 
and often keeps pace with the decline of sexual power. 
The nutrition of undescended testes is often much impaired, and marked 
wasting results. In persons who, in consequence of some defect in the struc- 
ture of the encephalon, experience little or no sexual impulse, the testicles 
often remain permanently dwarfed. 
Varicocele, when large, causing as it does considerable embarrassment in the 
circulation through the spermatic veins, will induce softening and alteration 
in the form of the testes. Excessive venereal indulgence or masturbation 
may so weaken the sexual power as to cause wasting. Indeed, any cause 
interrupting the proper supply of nerve-influence to the organs of generation, 
as pressure on the spermatic cord, paraplegia, injuries of the spine and the 
cranium, orchitis,-arising either from injury or as a sequel of mumps,-fre- 
quently lays the foundation for wasting. 
The long-continued use of certain medicinal agents, as iodine, has also the 
reputation of causing partial absorption of the glands; though this has not 
been verified in my experience. 
In all cases of wasting the epididymis suffers less than the body of the 
testis. 
Except in cases of inflammatory disease of the organ, the physician too 
often is powerless to improve the nutrition of the testicle. When impaired 
nutrition results from inflammation, the treatment required will be similar to 
that employed for the relief of orchitis. Where the demands on the sexual 
function have been excessive, and as a result atrophy of the testicle is induced, 
the wasting may be arrested by leading a chaste and continent life. 
When there is reason to believe that the atrophy is due to an aggravated 
varicocele, ligation of the veins may serve to check the progress of the affec- 
tion. In fine, any cause to which this alteration in the structure of the 
gland can be referred, and which is removable, should receive attention at 
once, in the hope that some good may be effected. 598 
INJURIES AND DISEASES OF THE GEN1TO-URINARY ORGANS. 
Dermoid Cysts.-Among the remarkable affections of the scrotum and tes- 
ticle which have been occasionally witnessed are cysts containing cartilage, 
bone, teeth, hair, etc. 
Tumors inclosing these organic remains are, of course, congenital. Ver- 
neuil* has collected ten cases of these cysts. It was the diagnosis of a 
tumor of this nature in 1840, by Velpeau, which gave to this eminent surgeon 
such a reputation for extraordinary sagacity. 
Dr. Harris, however, has shown that Velpeau was probably led to the con- 
clusion which he formed by the publication of two operations which had been 
performed, one in 1826, by M. Fatti, of Braunau, Austria, and the other in 
1829, by Professor Wendt, of Breslau, for the removal of scrotal tumors 
which were found to contain foetal remains. A knowledge of these cases, and 
the fact that a tuft of hair, in Velpeau's case, protruded through an ulcerated 
opening in the scrotum, would contribute very greatly to remove the ob- 
scurity of such a tumor and to lessen our surprise that its true nature had 
been properly conjectured. 
Various theories have been advanced to explain the presence of foetal 
remains in so unusual a locality. 
Velpeau and others have thought that these organic matters were origi- 
nally inside of the abdomen, in close relation with the testicle, and that they 
descended along with the latter during its migration to the scrotum. The 
view entertained by Geoffroy Saint-Hilaire is probably the correct one, which 
regards such remains as parasitic, being aborted or imperfect germs which 
are included in the body of another or perfect organization. 
The diagnosis of such a tumor would rest upon its congenital origin, upon 
the ability to discover something which, from its resistance and form, would 
convey the idea of bone, and, if ulceration has taken place, upon the probable 
appearance of hair or other foetal structures in the opening. Excision of the 
entire tumor, including the testicle, has generally been found necessary. 
Entozoa are rarely found in the testicle. Only two instances have been 
collected: one in the Hunterian Museum at Glasgow, and the other in the 
museum of the College of Surgeons, Edinburgh, in both of which a Guinea- 
worm (Filaria medinensis') was attached,-in the one case to the lower end of 
the vas deferens, and in the other to a tumor removed from the scrotum.f 
Castration is a very ancient operation. In the East it is performed as a 
punishment for state offenses, also to prepare a class of servants suited to 
the service of an imperial residence. The word eunuch is derived from two 
Greek words, a bed, and £/£»', to have or to keep, and thus signifies one 
having charge of the beds of the women. 
Castration was the natural consequence of the system of polygamy so 
prevalent in the East. In Greece, until the Byzantine period, the practice 
was quite uncommon. In Rome, under the emperors, many eunuchs were 
kept. In Italy, at one time, castration was practiced in order to secure a 
certain quality of voice, the soprano. At the present day eunuchs are found 
chiefly in Mohammedan countries. There is at Moscow, Russia, a commu- 
nity of eunuchs, who are jewelers by profession, and who add to their num- 
bers by the purchase and mutilation of children. At Tambov and the principal 
villages around Moscow, it is said, there are not less than twenty thousand 
of these fanatics. 
Though castration done early, as a rule, has the effect of materially changing 
both the physical and the moral constitution of the individual, causing an 
arrest in the growth and vigor of the body and of the beard, producing also 
a character full of intrigue and deception, there have been eunuchs who were 
Castration. 
* Archives G6n€rales de Medecine, 5me ser., t. v. et vi., 1855. 
f Curling on the Testis. CASTRATION. 
599 
by no means deficient either in energy or in ability. Bagoas, the Persian 
minister, was a eunuch, and also a soldier of Artaxerxes Ochus. He plotted 
against his master, and finally poisoned the king and several of his sons, 
but was himself put to death by Darius Codomannus, whom he had been 
instrumental in elevating to the throne of Persia. Philetserus, king of Per- 
gamus, and Narses, the Byzantine general, were also, though eunuchs, men 
of more than ordinary ability. 
We read in the New Testament of men being made eunuchs for the king- 
dom of heaven's sake; that is, men had voluntarily sacrificed their manhood 
in order that all temptation to fornication and adultery might be removed. 
The practice probably grew out of a wrong interpretation of the injunc- 
tion, " If thine eye offend thee, pluck it out," or " thy right hand, cut it off." 
In all enlightened countries the removal of the testicles is resorted to only 
on account of disease. 
Operation.-The hair being shaved from the pubes and scrotum and the 
patient placed in the recumbent position on a narrow table and brought 
under the influence of an anaesthetic, an incision should be made in the 
whole length of the tumor, beginning immediately below the external ab- 
dominal ring, and extending to the inferior boundary of the scrotum. The 
surgeon must be careful, even in large growths, not to include too much of 
the integument in his incision, as the contraction of the dartos will occasion 
a great deal of shrinkage. The coverings of the testicle and cord being 
divided, the gland is to be drawn out of the scrotum by traction, breaking 
up the cellplar attachments with the finger, and cutting those which do not 
readily yield with the knife. 
In thus dissecting out the tumor the septum must not be injured, nor the 
penis, both of which should be held out of the way. The testicle being now 
divested of all its coverings, the cord is to be cleared of its muscular and 
fascial envelopes, and the vas deferens separated from the other constituents. 
A pin should now be passed between the duct and the other constituents 
of the cord which contain the blood-vessels, and the latter secured by placing 
a ligature round the extremities of the pin, after the manner of the twisted 
suture, when the cord can be severed below and the testicle removed. (Fig- 
1350.) 
Some surgeons object to this mode of dealing 
with the cord, and prefer drawing out the sper- 
matic and deferential arteries and tying them 
alone, alleging that, by including the components 
in mass, unnecessary pain is given, and that there 
is danger of inflammation extending into the ab- 
domen. 
Though I invariably resort to this plan, I have 
never heard patients complain of any unusual pain, 
nor have I witnessed any unusual symptoms follow 
the practice. The operation is much more quickly 
done, gives a complete control of the cord subse- 
quently, and the ligature admits of being removed 
at any time, at the pleasure of the operator, by 
merely withdrawing the pin. Generally, this can 
be done safely on the third or fourth day after the 
operation. 
There is another reason which may be given for 
this mode of securing the vessels of the cord. 
The artery of the vas deferens is very small, dif- 
ficult to find, and often does not bleed at the time 
of the operation, thus escaping observation. If allowed to remain without 
being secured, hemorrhage will most certainly follow after the wound is 
closed. By the use of the pin this is made impossible. 
Should the surgeon prefer to tie the vessels separately with ligatures, a 
Fig. 1350. 
Mode of securing the vessels of the 
cord. 600 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
thread should be carried through the connective tissue of the cord before 
dividing it, so that in the event of its retraction within the inguinal canal 
he shall have the means of again drawing it out. There is a strong tendency 
in the spermatic cord, after being divided, to draw up; due partly to its elas- 
ticity and partly to the contraction of the fibres of the cremaster muscle. 
Benjamin Bell relates the cases of two patients who perished from hemor- 
rhage in consequence of this retraction taking place before the vessels were 
tied. 
The cord being disposed of, a careful and diligent search must be made for 
every bleeding vessel in the scrotum, and these, which often amount to six 
or seven, tied. Wherever a little clot is seen, let it be scratched off, as it often 
masks the orifice of an artery which will require a thread. This injunction 
of the operation should be strictly obeyed, as any neglect in its observance 
will probably subject the operator to the annoyance of reopening the wound 
on account of subsequent bleeding. 
After the ligature of the arteries the sides of the wound are to be brought 
together by interrupted sutures, the stump of the cord being included between 
them, and the parts covered with a piece of lint moistened with carbolated 
oil. and supported either on a cushion or in a sling formed by a broad strip 
of muslin, passed beneath the scrotum, and its ends fastened to a band sur- 
rounding the body. 
The contraction of the dartos, serving to keep the surfaces of the wound 
in close contact, contributes greatly to rapid healing, and thus we find that, 
if no complication occurs, the parts are well united in three or four days. 
The possibility of a hernia co-existing with a diseased testicle must not be 
overlooked in castration, as in such an event the intestine or omentum might 
be wounded through negligence. Should a hernia be present and recognized 
before the operation is begun, it must be reduced, and its retention, after the 
patient recovers, be maintained by the pad of a truss, applied over the inguinal 
canal and external ring. 
Usually the operation of castration is attended with little danger, except 
when it is found necessary to extend our incisions into the inguinal canal, in 
which case the patient is exposed to the risk of peritonitis. Indeed, when 
the cord within the canal is involved, the propriety of any operation is ex- 
ceedingly questionable. 
When death has followed castration, it has been due to erysipelas, pyaemia, 
secondary hemorrhage, or peritonitis. 
There are three conditions affecting the genital organs which are deeply 
concerned in disturbing the mental peace and happiness of many persons. 
They are impotence, barrenness or sterility, and spermatorrhoea. 
DISORDERS AFFECTING THE USE OF THE GENITAL FUNCTION. 
Impotence. 
Impotence may arise from both physical and mental causes. It may be 
either real or fictitious. By the term impotence is meant an inability to 
perform the sexual act. It does not by any means imply a defect in the 
seminal secretion, although this may be the case. 
The conditions necessary for the consummation of the sexual act are an 
erection sufficiently firm for the introduction of the male organ into the va- 
gina of the female, and the ejaculation of the seminal fluid. The physical 
causes which defeat sexual congress on the part of the male, and thereby 
render an individual impotent, are: 
1st. Absence of the penis,-an exceedingly rare defect. 
2d. Diminutive size of the penis, either natural or acquired (as in some cases 
of exstrophy of the bladder, or from amputation for disease), may render 
connection impossible; or the disqualification may be due to the disproportion IMPOTENCE. 
601 
between the size of the male organ and that of the vagina being such that 
the friction necessary to produce venereal orgasm cannot be obtained. 
It must not, however, be inferred that disqualification for copulation depend- 
ing on the deficient length of the male organ implies sterility. The power to 
deposit the semen, if only between the labia minora, is still an act of potency, 
and may prove a fruitful connection. There are numerous cases recorded in 
which pregnancy has taken place with an unbroken hymen. I am cognizant 
of a case in which a woman, who has had several children, has repeatedly 
declared that in consequence of premature ejaculation the vagina had never 
been entered. Her husband confirms this assertion. 
3d. Congenital malformation and malposition, as hypospadias, epispadias, in- 
curvations, and phimosis, may also cause impotence, by interfering with the 
proper projection of the semen. 
I have seen, however, a case of hypospadias in which the urethra termi- 
nated more than an inch short of the glans penis, but which did not in the 
least interfere with either potency or fruitfulness of intercourse, as the 
individual had a large family of children. 
In a case of very tight phimosis, I once operated successfully in order to 
remove a mechanical obstruction to the discharge of the semen. 
The accidents which may occur to the undescended testes are calculated to 
induce impotence. 
4th. Acquired alterations of structure are a very common cause of impotence. 
Thus, urethral fistulae opening on the perineum, or even through the spongy 
portion of the canal, will serve to divert the semen from the proper course. 
An enlarged prostate or a myo-fibroma, either by mechanical pressure or by 
changing the direction of the orifices of the ejaculatory ducts, may prevent 
the transmission of the seminal fluid along the canal, or cause it to pass into 
the bladder. Stricture of the urethra frequently offers an insurmountable 
obstacle to proper ejaculation, and a urethral calculus may act in the same 
manner. Inflammatory or cartilaginous deposits in the cavernous bodies of 
the penis, or cartilaginous degeneration of the septum pectiniforme, may pro- 
duce vicious curvatures in the virile organ, or may induce such structural 
alteration that while the posterior portion of the penis is capable of erection 
the anterior part remains flaccid, defeating all attempts at penetration. 
Again, imperfect turgescence of the male organ amounting to impotence 
is not unfrequently witnessed after attacks of syphilitic orchitis, carcinoma 
of the testicle, exhausting disease, masturbation, and abuse of the sexual 
organs; and in my own observation this sexual incompetence among young 
men is greatly on the increase, at least among the residents of large cities. 
It is said that in Asiatic countries, where polygamy and concubinage pre- 
vail, early impotence is much more common than among Occidentals,-a 
statement which has been corroborated by the observation of travelers. 
5th. Cerebro-spinal causes.-Injuries of the head, especially those involving 
the cerebellum, are productive not only of atrophy of the testis, but also of 
the loss of virile power. Larrey has particularly noticed this sequence, and 
cases corroborating the observation have been recorded by Gall, Smyth, 
Fisher, and others. Apoplexy, epilepsy, tumors, and softening of the brain 
are often accompanied by loss of erectile power, and a similar disability is 
frequently witnessed in the idiotic from imperfect development of the gen- 
erative organs. Severe concussions and lesions of the spinal marrow may 
also be followed by impotence. 
Any cause which tends to induce nervous exhaustion is sufficient to sus- 
pend temporarily, and sometimes permanently, the ability to perform the 
sexual act. It is thus that the intemperate use of tobacco and excessive 
venereal indulgence lay the foundation for impairing or destroying virility. 
6th. Disease of adjoining portions of the genital organs will also, by absorbing 
the integument of the penis, and encroaching on the latter, render copulation 
impossible; in illustration of which may be mentioned a large single or double 
hydrocele, elephantiasis of the scrotum, and voluminous hernia). 602 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
7th. Oxaluria is sometimes a cause of impotence,-a fact first noticed by 
Golding Bird; and when cases present themselves in which the power of 
erection is lost, and there appears no obvious reason for the disability, the urine 
should always be examined, especially if symptoms of indigestion are present. 
In addition to the above causes, temporary impotence not unfrequently is 
the result of feeble health or physical exhaustion. 
Treatment.-Some of the conditions which have been enumerated as 
producing impotence are irremediable, while others admit of being removed. 
Thus, in the impotence arising from hypospadias, the restoration of the 
imperfect urethra by a surgical operation is the remedy. When it is caused 
by phimosis, circumcision must be performed; and if due to narrowing of 
the urethra by stricture, the normal calibre of the canal is to be restored 
by dilatation, with or without incision. Syphilitic impotence is sometimes 
removed by a course of mercury or iodide of potassium. 
Premature emissions, depending as they so frequently do on an excessive 
irritability of the nerves of the prostatic portion of the urethra, require 
gentle cauterization, the use of alkaline diluents, gentle laxatives, and a 
course of strychnia and iron. 
Disability in consequence of hydrocele or hernia is to be removed in the 
former affection by tapping, and in the latter by reduction, when feasible, 
and the use of a truss. 
Impotence from oxaluria requires the administration of nitro-muriatic acid, 
and a properly-regulated diet, consisting largely of vegetable and farinaceous 
articles,-except rhubarb and tomatoes,-with milk, and only a moderate 
amount of meat; and when arising from nervous exhaustion or general con- 
stitutional weakness, rest, change of air, relief from all the cares, exactions, 
and anxieties of business, substantial food, and a course of strychnia, iron, 
and phosphorus. 
There are several agents which possess a certain degree of aphrodisiac 
power, some of them in virtue of the local irritation which is provoked by 
their use, as the tincture of cantharides and phosphorus; and, in cases where 
the erections are feeble, they may sometimes be employed to give a temporary 
energy to the virile organ. Electricity or electro-galvanism may also be used 
with a view to improve the nervous supply of the muscular apparatus of the 
genital organs, one of the electrodes (positive) being placed over the lumbar 
region or over the cord, and the other at the root of the glans penis, also 
over the perineum, the interrupted or faradaic current being preferable. 
Pseudo-Impotence, or Fictitious Impotence.-In many instances of impo- 
tence the causes are purely of a mental or moral character; and there is 
no other class of patients requiring such delicate and adroit management. 
Success will depend on a due appreciation of the interdependence which sub- 
sists between the mental and the physical. Among these causes may be 
mentioned want of confidence in the ability successfully to effect coition ; and 
if the first encounter should not be crowned with success, the second is always 
undertaken in a state of trepidation and anxiety, and is likely to end simi- 
larly; or the failure may result from an over-excitement which will not 
abide the delay incident to the natural obstacles to the consummation of the 
sexual act. Under these circumstances nothing further will be required than 
a few words of encouragement from the professional confidant, assuring the 
troubled spouse, in the first case, that confidence and potency will come with 
better acquaintance, and, in the second case, that time, exhausting the re- 
dundancy of erotic excitement, will remove the disability. 
Want of response, or sexual indifference on the part of the female, may 
effectually repress all desire for connection, and can be remedied only by the 
wife feigning what is really not experienced. Want of affection, disgust at 
some act, or the escape of an unfortunate expression, may all prove instru- 
mental in defeating copulation. 
A case was communicated to me in which, in consequence of the homely STERILITY. 
603 
face of his wife, the husband could only by concealing her head have a suc- 
cessful intercourse. In other instances, in the absence of personal attractions, 
men have been compelled, in order to effect copulation with a companion, to 
think of some other woman. 
Men have confessed to me that the consciousness of being unfaithful to the 
lawful bed has rendered them utterly impotent in the company of a strange 
woman. 
Sterility. 
Sterility, or an incapacity to beget children, depends, first, on some defect 
in the spermatic fluid; secondly, on some functional or inorganic inability to 
deposit the sperm within the vagina. 
First. The constituents of the semen necessary to fecundation are sperma- 
tozoa. These are much oftener absent than is generally supposed. Until the 
age of puberty the secretion of the testes is devoid of zobsperms, and again 
in advanced life, when the sexual powers are on the decline, these bodies, 
losing first the tails and finally the heads or the cells, begin to disappear. 
Nevertheless, there are some persons whose fecundating power remains 
to a very late period of life. A patient once under my care begat children 
at eighty years of age. Cato, the Roman censor, bad a son born to him at 
eighty. Ladislaus, King of Poland, had two sons after the age of ninety. 
Pliny states that Masinissa had a son born to him after eighty-six. Palla- 
vicini, on the authority of Savonarola, had a son at one hundred years of 
age; and an instance is given by Lemnius of a man who, at the age of one 
hundred, married a young woman, by whom he had several children. 
These are, however, rare exceptions to the general rule, that after seventy 
the potency of the male is greatly lessened, and with it the power of fecun- 
dation. 
The secretory power of the testes may be so exhausted by sexual excess 
that the zobsperms entirely disappear. Such a condition, however, would 
not justify the conclusion that an individual presenting so important a defect 
in the spermatic fluid was permanently sterile, as a few weeks of continence 
might be sufficient to restore the functional perfection of the glands. In 
progressive atrophy of the testicle, either as a result of inflammatory changes 
or from the want of a sufficient amount of blood, the spermatozoa disappear. 
Indeed, the same is true in all cases of syphilitic, strumous, or malignant 
disease of the testes. The testicle which remains sound is, however, not 
necessarily disabled by the disease of the affected one. 
Malposition being generally associated with imperfect development of the 
testes, the secretion of these glands is very frequently found deficient in an 
impregnating fluid. Nevertheless, while this is the rule, there are not want- 
ing instances of cryptorches having begotten children. If one testicle is in 
the scrotum, and sound, though the othei' may never have descended, the 
individual is not necessarily sterile. 
Secondly. Inability to deposit the sperm within the vagina (dyspermatisrn') 
may result from various causes. The penis may be absent either congenitally 
or accidentally, in which case sterility must follow. The same will be true 
if the excretory ducts of the epididymis have been occluded by inflammation, 
as sometimes happens after a severe epididymitis. A gentleman of this city, 
whose wife was having children in quick succession, was attacked with an 
unusually severe epididymitis of the left testicle, followed in a few days by 
an inflammation of the right epididymis, each of which was left with a hard 
knot in the globus minor, which remained unresolvable. The spermatic fluid 
contains no zobsperms, and, though the patient is entirely potent, intercourse 
has proved fruitless ever since his recovery. 
This corresponds to what has been observed by Gosselin, who examined 
the sperm in twenty persons who had suffered from double epididymitis, and 
in all the spermatozoa were absent from the semen. Only two of the pa- 
tients, however, was he able to keep under prolonged observation, and in 604 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
these, as the induration of the epididymis disappeared, the zoosperms were 
again found in the spermatic fluid. 
Injury to the ejaculatory ducts inflicted in the operation of lithotomy, not 
an uncommon occurrence, may also interfere with the passage of the semen. 
Another source of inability to introduce the semen into the vagina is stric- 
ture of the urethra, particularly when the canal is so coarctated as to offer 
a serious mechanical obstacle to the passage of the spermatic fluid. Many 
persons are rendered incapable of fruitful connection by this cause, the semen 
dribbling away for hours after intercourse, instead of being discharged per 
saltum, the ejaculation being delayed until the erection has subsided. Any 
mechanical obstruction of the urethra, as the presence of a polypoid growth, 
or the impaction of calculus, may be followed by a like result. 
The loss of the ejaculatory power constitutes another cause, under the 
head of dyspermatism, for unfruitfulness. It is the act of ejaculation taking 
place at the culmination of the sexual orgasm which propels the semen in 
jets from the urethra into the vagina of the female. Its failure to occur 
necessarily involves the absence of a condition essential to impregnation. 
Spermatorrhoea. 
Spermatorrhoea, or the flow of semen, may occur under very different con- 
ditions. It may be voluntary, as in self-abuse or masturbation ; or involun- 
tary, as in diurnal or nocturnal pollution; and it may consist in a passive 
loss of the secretion without the consent of the will, and without ejaculation 
or pleasure. 
Causes.-The causes of spermatorrhoea are both physical and somatic. 
The secretion of the testes after puberty is not an intermittent process, but 
a constant one. Except, however, under excitation, the spermatic fluid is very 
slowly formed, and it is only when the stimulus of excitement is present, and 
particularly when the desire for connection remains ungratified, that the 
seminal secretion accumulates to an extent which tends to provoke frequent 
ejaculations during sleep. As the sexual organs are greatly influenced by 
the brain, any impressions of a lascivious nature are calculated to induce an 
exaltation of the secretory functions of the testicles. Thus, when the rein 
is given to lewd thoughts, to impure reading, or to the contemplation of 
sensual exhibitions, the seminal passages become surcharged with the sper- 
matic fluid, the plethora from which induces emission. Lascivious dreams, 
which are so frequently the immediate excitants of ejaculation, are in many 
instances the direct result of mental impressions made during waking hours. 
Among the somatic causes are inordinate sexual indulgence, which, by 
making frequent draughts on the testes, and attended as it is with a con- 
stant repetition of nervous shocks, finally gives rise to a preternatural irrita- 
bility of the entire sexual apparatus, which leaves it extremely impressible 
to reflex influences, whether derived from the mind or from the body. In 
this condition an erotic thought, the near approach of a female, or the friction 
of the clothing against the glans penis is sufficient to produce an involuntary 
ejaculation of the seminal fluid. 
Again, both unusual secretion and expulsion of the semen may be pro- 
voked by irritation in contiguous organs, which, though not directly con- 
nected with the testicles, are, nevertheless, indirectly related to them by 
nervous lines of communication. Thus, rectal disease, as hemorrhoids, fissure 
of the anus, and ascarides, cause involuntary pollutions by reflex action. In 
the same manner cystitis, vesical calculi, stricture of the urethra, and inflam- 
mation or congestion of the prostatic urethra induce ejaculations. 
By far the most common cause of spermatorrhoea, however, is masturbation, 
-that is, friction by the hand until the venereal orgasm is reached. This 
vice is common in both sexes, but much less so in females than in males. 
The former are less under the influence of animal passion, and the native 
modesty peculiar to the sex renders the incitement to such indulgences, with SPERM A TORRHCEA. 
605 
very few exceptions, very feeble indeed, and not often self-evoked. The 
dominance of the sexual appetite in the male crops out very early in life, 
erections in young children being matters of common observation. Nurses 
often lay the foundation for future masturbation by handling the sexual 
organs of male children with a view to prevent fretting or restlessness. Boys 
acquire the habit of self-abuse from their associates at school, and not un- 
frequently from their seniors. The irritation occasioned by a tight prepuce 
or phimosis is frequently alleged to be another exciting cause of this vice. 
The practice is not confined to man. Many of the lower animals are equally 
addicted to a similar habit, as the monkey, the goat, etc. 
Injuries of the head are occasionally concerned in the production of mas- 
turbation. This was notably so in the case of a celebrated clown, who died 
in the insane department of the Philadelphia Almshouse. Utterly devoid of 
shame, he would constantly indulge in the practice in the most public manner. 
The habit began shortly after a blow received on the back of the skull from 
a slung-shot. The skull after death was found to have a marked depression 
immediately below the superior semicircular ridge of the occipital bone. 
When the habit of masturbation has been once acquired, it exercises the 
most despotic tyranny over its victim, so that even when he is conscious of the 
evil and dangerous consequences sometimes resulting from the continuance 
of the vicious indulgence, so imperious is the passion that there is not suf- 
ficient power of will left to refrain. 
It must not be forgotten, however, that masturbation and spermatorrhoea 
are sometimes symptoms rather than causes of disease, and that, as Sir 
James Paget has very forcibly said, " even among the insane there are many 
of whom it would be truer to say that they masturbated because they were 
insane, than that they became insane because they masturbated." 
Interesting statistical proof of the relations between organic disease of the 
nerve-centres, masturbation and its attendant evils, and actual criminality, 
may be found in the report for 1875 of the surgeon of the Eastern State 
Penitentiary, Dr. J. Wm. White, to the Board of Inspectors. The physical 
and mental condition and family history of those convicts known to be con- 
firmed masturbators were compared with those of the rest of the prison 
population. Of all those in confinement, 58 per cent, were received in im- 
paired physical or mental health, or were considered likely to develop disease 
from inherited defect, while of the onanists, 85 per cent, were the subjects 
of mental or physical disease at the time of admission, or were hereditarily 
predisposed to such disease. Thirteen per cent, of the entire population of 
the prison had been convicted of crimes of an emotional character,-" crimes 
of the passions;" among the masturbators, 56 per cent, had been guilty 
of crimes of this class. The deaths from diseases of the nerve-centres were 
four times as frequent among these prisoners as among those guilty of crimes 
against property. Twenty-five per cent, of all the prisoners had been con- 
victed more than once; 46 per cent, of the onanists had been reconvicted, 
that is, approached more or less nearly to the class of habitual criminals. 
The practical deduction from these facts, which are considered at length 
in Dr. White's report, is that wre should be guarded in our prognosis and 
treatment of the nervous affections so frequently found associated with mas- 
turbation and spermatorrhoea, and should not err by attributing to the 
latter undue etiological power, when the truth is that they are often only 
effectual in exciting disease when there already exists a powerful predisposi- 
tion to it. The careful surgeon, therefore, before commencing the treatment 
of a case of this character will search for any possible constitutional defect, 
-inherited or acquired,-examining especially the condition of the nervous 
system, and endeavoring by every means in his power to eliminate the pos- 
sibility of mistaking a local manifestation of general disease for the disease 
itself. 
The symptoms which follow abuse of the sexual organs are involuntary 
emissions occurring during sleep, occasioned generally by lascivious dreams. 606 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
These are repeated sometimes for several consecutive nights, or even twice 
in a single night. If allowed to continue unchecked, they are liable to occur 
either entirely without erections or with very feeble erections during the 
night, and even in the course of the day, on the slightest provocation, and 
finally may terminate in a spermatorrhoea, the spermatic fluid escaping 
during defecation or in other straining efforts, unattended by any ejaculatory 
orgasm or pleasurable sensation. The general health at length begins to fail. 
The patient loses bis appetite; is annoyed with symptoms of indigestion, as 
flatulence, uneasiness after eating, abdominal distention, and costiveness; 
loses flesh; grows weary on taking even moderate exercise; has a languid, 
dull appearance; the skin becomes discolored under the eyes; the vision is 
often impaired; he complains of palpitation of the heart, pains in the loins, 
and a sense of great fatigue, especially after an emission. The moral effect 
of the disease is also very noteworthy. The patient becomes greatly de- 
pressed in spirits, melancholy, avoids society, has a shy, downcast look, 
blushes, is absent-minded, with defective memory, and is often disqualified 
for the pursuit of any business. Not unfrequently the individual thus affected 
is rendered practically impotent, the testicles become soft, and the scrotum 
is relaxed and elongated. 
Treatment.-The treatment of spermatorrhoea is prophylactic and cura- 
tive. To prevent the formation of the habit of masturbation in a boy should 
be a matter of the first importance. With this view a careful watch should 
be kept over nurses to see that they do not handle the organs of the child. 
A long prepuce should be removed. Boys, especially if of different ages, 
should not be allowed to sleep together. When there is reason to believe 
that a lad has commenced a practice of this nature, he should be taken at 
once into the confidence of the male parent or the family physician, and, by 
appealing to his noblest and best qualities, an endeavor should be made to 
strengthen his feelings of self-respect and manliness, and to enforce with ten- 
derness and kindness the obligation to live a pure and chaste life. Much more 
will be gained by a course of this kind than by one which appeals to his 
fears. Young children who have been educated into the habit can only be 
restrained by watchfulness, correction, and, if necessary, by confining the 
hands in such a manner that they shall be unable to finger the parts. 
There are many persons whose lives are perfectly pure, and who are not 
chargeable with any secret sexual vice, in whom, from the possession of strong 
sexual powers, there occurs an occasional nocturnal seminal ejaculation. This 
may happen once or twice a week, and yet indicate nothing more than an 
unusual plethora of the spermatic receptacles; indeed, it may be deemed 
purely a salutary act. 
Nevertheless, to persons who are ignorant on the subject of sexual 
hygiene, or who, perchance, have had the misfortune to read the circular of 
some unprincipled charlatan, these periodical emissions assume the greatest 
importance, and awaken fears with reference to the probable loss of man- 
hood, which seriously interrupt their happiness and welfare. Here the duty 
of the physician is first to assure the patient that his apprehensions are 
groundless, and that his case is not one of disease at all. This will restore 
his peace of mind, and remove at once that anxiety and apprehension which 
are calculated to perpetuate the self-pollution. These are the cases which 
are sometimes advised to indulge occasionally in sexual intercourse; and 
there is no objection to this if it is legitimate, and where a proper marriage 
is practicable, its consummation will be the surest plan of getting rid of 
this kind of seminal incontinence. No one, however, can justify an act of 
fornication on the ground that the sexual appetite craved indulgence; and 
all teaching to the contrary is in direct contravention to the moral law. To 
advocate an opposite doctrine would be to give the leash to the worst pas- 
sions of men, and to sweep away the most effectual safeguards to purity and 
virtue. When circumstances prevent marriage, the individual must be in- 
structed to lead an active life, to avoid the contemplation of all subjects SPERM A TORRHCEA. 
607 
calculated to appeal to the animal passions, to use a plain, unstimulating 
diet, to keep the bowels regular, and to rise after the turn of the night and 
empty the bladder. Such a course will confine these occasional emissions 
within harmless limits. 
It is more particularly with cases where self-abuse has been long practiced 
that we have to do. Patients who apply for relief under these circumstances 
generally readily confess their weakness. Of course, if masturbation is prac- 
ticed it must be abandoned, as a preliminary measure to all other treatment; 
though in most instances where professional counsel is sought the patient 
has long ceased to indulge in this habit. He is suffering from the effects of 
nervous exhaustion; the digestion is disordered; voluntary erections are 
feeble, or perhaps impossible; nocturnal pollutions are very frequent, and he 
is in a condition of great mental gloom and despondency. 
The treatment must be general and local, both of which will be greatly 
promoted by administering to the moral sense of the patient, giving him all 
reasonable assurance that the case is one which admits of relief, and then 
exacting a radical change of life and habits. The mind must be occupied 
with pure and elevated subjects of thought; consequently, the books which 
the patient reads, the companions with whom he associates, the occupations 
in which he engages, and the amusements in which he participates should all 
be of such a character as to appeal to the best qualities of the man. 
The medical treatment should be directed to the correction of the digestive 
organs, to the removal of all sources of reflex irritation of the generative 
organs, and to the imparting of tone and vigor to the system at large. In 
fulfilling these indications, all articles of food calculated to oppress or tax the 
stomach must be discarded. Generally the diet which can be used with the 
least inconvenience consists of broiled or roasted meat, as beef, mutton, or 
game, good bread, eggs, white potatoes, rice, or milk, the digestion of which 
will be rendered more easy by taking at each meal five grains of pepsin. 
The patient should be much in the open air, at the same time avoiding all 
fatigue, in order that the nervous energy may not be unnecessarily exhausted. 
To these may be added general and local bathing. 
Not unfrequently a change of scene will exert a salutary influence, espe- 
cially when there is much depression of spirits. As a further means of im- 
proving the general health and restoring nerve-power, tonics can be given 
with great advantage, as iron, quinine, strychnine, and phosphorus, also the 
mineral acids, and, where there is loss of flesh, cod-liver oil. It will be of the 
first importance to ascertain if there exists any local irritation in contiguous 
organs which may be reflected injuriously on the spermatic passages and 
thus provoke involuntary ejaculation of the seminal fluid. It may be that 
the urinary secretion will be found loaded with urates, phosphates, or oxa- 
lates ; and this condition must be corrected by the use of the infusion of a 
bitter tonic, as gentian, with the addition of nitric or nitro-muriatic acid. 
If the bowels are sluggish and the ffeces linger in the rectum, their daily 
dislodgment must not be overlooked. I have alluded to the necessity of 
emptying the bladder during the after-part of the night in cases of sperma- 
torrhoea. This is an indispensable part of the treatment. The night-urine, 
in consequence of the inactivity of the cutaneous glands, is much more highly 
charged with solid matters than the urine which is passed during the day, 
and, consequently, when the bladder becomes somewhat distended with this 
concentrated secretion during sleep the irritation which follows is propagated 
along the nerves to the muscular apparatus concerned in the expulsive orgasm, 
and an emission follows. 
It is this reflected irritation which induces morning erections. 
Many times have I succeeded in arresting nocturnal pollutions by urging 
the necessity of emptying the bladder at two or three o'clock in the morning, 
as it is during this part of the night that emissions are likely to occur. This 
precaution should never be neglected in cases of spermatorrhoea. 
Besides the irritation transmitted from the bladder, there is not unfre- 608 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
quently another, located in the prostatic urethra, which is equally capable 
of causing emissions. Its existence is readily recognized by passing a soft 
bougie along the urethra: the extreme sensibility of this part of the canal 
will be discovered as soon as it is reached by the instrument. As it is in the 
prostatic urethra that the ejaculatory ducts empty, all morbid impressions 
on its mucous surface are quickly transmitted thence to the seminal vesicles. 
Hence the necessity of early removing any vascular fullness or undue sen- 
sibility which may exist in this section of the urethra by proper local appli- 
cations, the best being the nitrate of silver, varying in strength from forty 
per cent, to the pure salt. The application is most conveniently effected by 
the instrument of Lallemand (Fig. 1351), which is a catheter-shaped canula, 
containing a stylet with a spherical termination, and near the end of which 
Fig. 1351. 
Lallemand's urethral porte-caustic. 
is a little cup for the reception of the crayon of caustic; this, after being 
charged and carried down the urethra to the prostatic part of the canal, is 
protruded and rotated two or three times in quick succession, then drawn 
into the canula, and the instrument removed. 
This may be repeated two or three times-never more-at intervals of ten 
days. It is usually followed by some smarting pain and scalding urine. 
Occasionally, though quite rarely, the cauterization is succeeded by retention 
of urine; but this soon yields on taking a hot hip-bath and injecting into 
the bowel thirty drops of laudanum in a little starch-water. The caustic 
application is also sometimes followed by a slight bleeding from the urethra; 
but this soon subsides spontaneously. 
After cauterization it is quite common for the patient to have a temporary 
increase of the emissions; but these soon subside, and in many cases they 
are permanently prevented. There is no doubt that much harm is done by 
the indiscriminate application of caustic agents to the urethra. They may 
be followed by an irritable bladder, by cystitis, and by epididymitis. The 
cases where cauterization does good are those in which there is extreme 
sensibility of the prostatic urethra, and are generally met with in chronic 
examples of the disease. 
The power possessed by the bromide of potassium of lowering the sensi- 
bility of the spinal cord and brain renders this drug valuable for the purpose 
of procuring sleep and preventing dreams, and thereby diminishing the irrita- 
bility of the sexual organs. 
Different mechanical appliances have been devised to stop the nocturnal 
emissions, some of which are designed to prevent the patient from occupying 
an unfavorable position during sleep,-as on the back. With this view it 
has been directed to wear a long towel round the body when retiring to bed, 
with a knot so placed as to rest directly over the spine and so cause sufficient 
discomfort, in the event of the dorsal position being assumed, to awaken 
the patient and compel him to turn upon the side. Rings having teeth 
somewhat sharp have also been worn over the penis. These contrivances 
are placed upon the organ in its flaccid state. If an erection occurs, the 
pain caused by the teeth pressing into the integument will be sufficient to 
rouse the person from his rest before ejaculation. With the same object CONGENITAL DEFECTS OF THE BLADDER. 
609 
in view, perineal trusses are sometimes worn, which, by pressing firmly in 
front of the anus, are supposed to offer an obstacle to the escape of the 
spermatic fluid. 
Trousseau has commended the use of an olive-shaped metallic compressor, 
to be worn in the rectum during the night, so adjusted as to make pressure 
against the prostate body and the seminal vesicles. 
When there exists a passive flow of the spermatic fluid,-an uncommon 
condition,-or when it escapes during defecation, much benefit will be derived 
from the free use of strychnia and the fluid extract of ergot, conjoined with 
the cold hip-bath and electricity. 
In aggravated cases of spermatorrhoea, which have persisted in defiance of 
all remedial measures, the surgeon will sometimes be consulted with regard 
to the propriety of castration. I can conceive of no circumstances justifying 
such a mutilation. The operation has been done without producing any 
alteration of the mental symptoms: indeed, the very consciousness of being 
emasculated has precipitated the unhappy victim into a still deeper despond- 
ency, and even forced him to take refuge in self-destruction. 
There is another question upon which the surgeon will be consulted, namely, 
the propriety of a person marrying whose sexual powers have been greatly 
enfeebled by long-continued spermatorrhoea. No one under such circum- 
stances should be encouraged to assume a relation of this kind. It would 
only tend to further exhaustion, and consequently lessen the prospects of 
recovery. Patients should not be deceived in a matter so vital to human 
happiness; for while many persons whose virility has been greatly enfeebled 
do recover sufficiently to consummate the sexual act, there are many others 
who are never able to meet even the most moderate exactions of marital 
life, and it is no exaggeration to say that when the potency of the genital 
organs has once been seriously impaired by secret abuse the original vigoi' of 
function will never be regained. 
Congenital Defects of the Bladder. 
Under this head are included absence of the bladder, supernumerary blad- 
ders, malposition of the bladder, and exstrophy. 
Absence of the bladder is an exceedingly rare occurrence, only a few in- 
stances of this nature having been observed. When the defect exists, the 
ureters open into the urethra, the rectum, the vagina, or at the median line 
of the body. 
Lieutaud gives a case in which the ureters, much increased in size, opened 
close to the orifice of the urethra and immediately below the pubes.* This 
person was a man thirty-five years of age. A second case is given by Bin- 
ninger, in which the bladder was absent and the ureters opened into the 
urethra.f Richardson mentions an instance in which the ureters terminated 
in the rectum. The lad, at the time seventeen years old, had never passed 
any urine through the urethra, and hence the inference was fair that no 
bladder existed. The only inconvenience experienced was a troublesome 
diarrhoea. 
Camper has collected five similar cases, and Klein one.£ Several cases are 
recorded by Haller in his Physiology in which the ureters terminated in the 
bladder. Schroeder has given examples of the same kind. I was consulted 
in a case of a similar nature in a lady living in the northern portion of 
Pennsylvania. 
These abnormities are sometimes found associated with other irregularities 
of development, as in the case reported by Dr. Raphael, of New York, in 
which, in addition to the absence of the bladder, there were imperforate 
anus, undescended testicles, and absence of the colon. The ureters ter- 
* Hist. Anat. Med., Liber primus, obs. 1361. Cyclopaedia of Anatomy and Physiology, 
j- Obs. Med., 24, cart. 2. Cyclopaedia of Anatomy and Physiology. 
J Rachit. Congenit. Nov. Eph. ac Nat. Cur., vol. i. obs. 38. 
VOL. 11.-39 610 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
minated in a sac, which protruded at the umbilicus, and which contained 
the intestine. This example of monstrosity died nine days after birth. 
A case somewhat similar to the above was observed by Dr. Todd,* of Lon- 
don. The subject of the abnormity was a female foetus, which survived a 
few days. The ureters opened, one on each side of the pubes, through the 
abdominal parietes. Only about one inch of the large intestine existed, and 
the lower portion of the rectum and the expansion of the oblique muscles of 
the abdomen were absent. 
Supernumerary Bladders.-Many of the cases reported to have been of this 
charactei* were merely examples of the sacculated bladder, and, of course, 
deficient in muscular fibres. Even in those cases where the coats of the 
supernumerary bladder were complete, the irregularities might, in most 
instances, more properly be considered as instances of multilocular bladders, 
as the pouches all opened into a common reservoir. This is probably the 
explanation of the case mentioned by Professor Scibelli, of Naples, in which 
three bladders are described as being present; two, however, were continuous 
with the ureters, and were possibly dilatations of those ducts rather than 
additional bladders. In other cases the bladder was divided into two nearly 
equal halves by a partition, either with or without an opening for lateral 
communication. Angelo Scarenzi's case belonged to the first category, and 
the one of Blasius to the second, a ureter opening into each compartment. 
Bromfield describes a similar conformation, and Morgagni has collected 
others of a like character. Fantoni, in his Anatomy of the Human Body, 
has described a case which was probably one of multiple bladders. The 
most remarkable of all examples of a plurality of urinary bladders is that 
recorded by Molinettif of a woman who bad five bladders, five kidneys, and 
six ureters. Two of the ureters emptied into the largest of the bladders, and 
the remaining four each into a separate bladder. 
Malposition, or Hernia.-Displacement of the bladder may be both congen- 
ital and acquired,-generally the latter, when it is called cystocele. 
The protrusion may occur at the linca alba in consequence of some weak- 
ness of the parietes in this situation, eithei* from extreme distention of the 
walls by ascitic fluid, from a previous abdominal section, or from advanced 
age. 
The bladder may also be displaced through one of the hernial passages, as 
the inguinal, the femoral, the obturator, or the ischiatic, either with or with- 
out a portion of the intestine or omentum. When occupying some of these 
unusual situations, it has been confounded with hernia, diseased testicle, and 
abscess. 
Two cases are noted by Pott in which, in operations for strangulated 
hernia, the bladder was wounded. The same surgeon opened a scrotal 
swelling, which contained the bladder, under the supposition that he was 
dealing with a diseased testicle; and Verdier gives cases in which cystocele 
of the groin was mistaken for abscess. Vaginal cystocele is quite common 
in females who have borne children, the organ sometimes passing entirely out 
of the vulva. The bladder lias been known to become prolapsed during par- 
turition, and, being pressed upon by the head of the child, has been opened, 
under the supposition that it was a hydrocephalitic head. 
When the bladder is thus displaced it is without any peritoneal sac (a 
peculiarity first mentioned by Dominique Salla), unless where it has followed 
a large hernia, or where a very large portion of the organ is prolapsed. 
The causes which are concerned in forming a cystocele are twofold: first, 
unusual dilatation of the bladder from frequent attacks of retention, followed 
by straining efforts to empty the viscus ; and, second, a weakened condition 
* Cyclopaedia of Anatomy and Physiology, vol. i. p 370. 
f Philosophical Transactions, vol. vii. EXSTROPHY. 
611 
of the parietes corresponding to those portions of the abdomen through which 
the great blood-vessels pass. 
A cystocele must necessarily produce such an alteration in the form of the 
bladder that all the urine cannot be thoroughly expelled, and, as in the sac- 
culated organ, a portion will remain, and cause, by its decomposition, those 
changes in the mucous membrane and in the secretion which are likely to 
result in the formation of stone, examples of which have been given by 
Ruysch, Paget, Petit, and others. 
The diagnosis of cystocele, when not complicated with hernia, is not diffi- 
cult to establish. 
The tumor will be seen to increase with the accumulation of the urine, and 
to diminish during urination or catheterization. The sensation imparted to 
the fingers on pressure, palpation, or percussion is one of fluctuation, and 
not doughy, as in epiplocele, or elastic, resonant, or gurgling, as in enterocele. 
In doubtful cases the grooved needle should be employed, and any fluid 
obtained subjected to such tests as will determine its character. When the 
viscus becomes strangulated, there are no signs corresponding to those of 
intestinal strangulation present. The vomiting, it is said by Petit, in hernia 
of the bladder is always preceded by hiccough, while in intestinal hernia 
this symptom follows the vomiting. 
Treatment.-The treatment of cystocele consists in emptying the organ 
of urine, either voluntarily by the efforts of the patient, or by the catheter; 
during which pressure should be made on the swelling, when, if it has not 
formed adventitious adhesions, it may be restored to the pelvis, after which 
a truss must be worn, as in hernia, to prevent a second protrusion. 
When the tumor proves to be irreducible, the indication will be to prevent 
its increase; and this will be most effectually secured by employing a truss 
with a concave pad, made to conform to the rotundity of the swelling. 
When the prolapsus takes place into the vagina, passing, as it not unfre- 
quently does, external to the vulva, little can be done except by an operation, 
and this is liable to fail. (See Cystocele.') 
The various operations, which I have performed several times, will be 
described under the surgical diseases of females. 
Inversion of the bladder, in which the organ becomes prolapsed to some 
extent through the urethra, can occur only in females whose urethrae are short 
and susceptible of very great dilatation. Examples of this form of extro- 
version are exceedingly rare. 
Chopart, quoting from Percy, mentions the case of an abbess, fifty-two 
years of age, in whom the fundus of the bladder protruded through the 
urethra. It could be readily reduced with the finger, but immediately re- 
appeared after removing the pressure. 
Joubert records another case in most respects like that of Percy. 
Treatment.-Extroversion may be treated by repeated cauterizations of 
the urethra with the hot iron, during which the bladder must be kept in 
place by a catheter. Dr. Lowe effected a cure in one case by this plan. 
Incomplete inversion has been noticed in the male, but confined entirely 
to the mucous membrane of the bladder, and then not extending beyond the 
membranous portion of the urethra, as in the case narrated by Dr. Sam- 
berger.* 
Exstrophy.-This is much the most uncommon of all the irregularities of 
vesical formation. It is met with in both sexes, but more frequently in the 
male. In twenty cases collected by Mr. John Wood, two were found in females. 
Mr. Earle, in sixty-eight instances of exstrophy, states that eight only were 
in females; and in fifty-three collected by myself from different sources, seven 
were in females. 
This malformation consists in an absence, more or less complete, of the 
* Diss, de Intussuscep. Membr. Urethrae, 1795. 612 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
anterior walls of the bladder, with generally a deficiency in the anterior 
parietes of the abdomen, and a corresponding absence of the pubic sym- 
physis. The pubic bones, though generally separated some distance from 
each other, and having a band of fibrous tissue bridging over the space 
between the two, yet are in some cases in contact. The posterior wall and 
fundus of the bladder protrude forward, its mucous membrane forming a 
red, spongy-looking surface covered with vesical mucus, on which may be 
discovered the openings of the ureters, which are sometimes considerably 
dilated. The size of the extroversion varies, according to the age of the 
patient and the degree of abnormal pubic deficiency, from that of a walnut 
to half the palm of the hand. 
The margin of the opening in the anterior parietes through which the 
posterior wall of the organ projects, is generally irregularly oval. In typical 
cases the umbilicus is wanting. The penis also participates in the vice of 
conformation. It is stunted, turned backward, flat, and has a gutter on its 
upper surface, which is the lower semi-circumference of the urethra. At 
the vesical extremity of the latter may be seen a dwarfed prostate, prostatic 
sinuses, and the intermediate veru montanum, with the little slits marking 
the terminations of the ejaculatory ducts. This defect constitutes a com- 
plete epispadias of the organ. In some instances the cavernous bodies are 
separated from each other for a considerable extent posteriorly. The scrotum, 
though generally present, may be altogether absent. 
There is usually present in these cases of marked exstrophy double inguinal 
hernia, the intestines passing down into the scrotum, the division of which, 
by the intermediate notch or depression resulting from the extent of the 
interpubic space, gives to its halves the appearance of the labia majora of 
the female. 
In the absence of the scrotum the testes are generally situated in what 
would correspond to the inguinal canal, and are normal in size and structure. 
The mucous membrane which protrudes, being exposed to the friction of 
the clothing, to the action of the air, and to a highly-alkalinized and de- 
composing urine, is constantly in a chronically-inflamed state, while the 
thighs, the lower part of the abdomen, and the perineum and nates, together 
with the clothing, are constantly wet with ammoniacal urine, altogether 
rendering the subject of this horrid malformation an object of sincere com- 
miseration. 
There are other cases of extroversion of a much less pronounced character, 
in which the genital organs are not involved, where the pubic bones, though 
not firmly united by intermediate cartilage, are in near juxtaposition, and 
bound to each other by interlacing bands of fibrous tissue, the vicious con- 
formation being limited to the space between the hypogastric portion of the 
recti muscles and not reaching to the umbilicus, the latter being present and 
properly formed. 
This peculiar malformation has been studied by embryologists, and is shown 
to be an arrest in the anterior development of the lateral portions of the al- 
lantois, the blending of which in the median line is necessary to the comple- 
tion of the anterior lateral walls of the bladder. This vice in development 
does not destroy the venereal appetite, though such persons are necessarily 
unable to effect successfully the sexual act. 
In exstrophy of the bladdei' in the female there is the same defect in the 
symphysis pubis, though not to the same degree, as in the male. The cleft 
extends backward, separating the labia majora and labia minora, and the 
vagina appears as an elongated, transverse fissure, being also more shallow 
than normal. The deformity causes less sexual disability in the female 
than in the male, and, as the uterus and ovaries are not necessarily involved 
in the defect, it is not incompatible with sexual intercourse and conception, 
of which there are cases recorded-one by Dr. Huxharn and a second by 
Thiebault-in which parturition occurred. Todd refers to one of the anatom- 
ical abnormities which sometimes accompany exstrophy, related by Bartholin, EXSTROPHY. 
613 
in which, in addition to the defect in the anterior wall of the bladder, the 
penis and anus were both absent, all the ingesta taken by the individual re- 
turning by the mouth for forty years. The deformity of exstrophy, though 
a horrid and disgusting one, is not inconsistent with long life. Flajani speaks 
of one case living at seventy, and Quatrefages of others of forty-nine. A 
man well known to the medical students of Philadelphia, who appears annu- 
ally before the classes, and whose exstrophy constitutes his whole capital in 
trade, is forty years old. 
Treatment.-Whether the treatment is mechanical or operative, the object 
must be the same, namely, palliative. 
The mechanical appliances which have been devised with a view to collect 
the urine have all signally failed to accomplish the object. The best appa- 
ratus of the kind is that designed by Mr. Earle, one of the surgeons of St. 
Bartholomew's Hospital, London, which consists of a concave cup of metal, 
with a rounded border, designed to make a harmless depression in the integu- 
ment surrounding the extroversion, but not to touch the mucous membrane 
at any point, and secured in place by a strap 
buckled round the pelvis like a truss. At the 
lower part of this shield is a tube connecting with 
a gum bottle, which is fastened to the thigh, and 
into which the urine is directed. (Fig. 1352.) 
Various ingenious operations have been origi- 
nated for the relief of extroversion of the bladder, 
some of which have been quite successful. The 
experiment of establishing a communication be- 
tween the ureters and the rectum has been tried 
by Mr. Simon and Mr. Sidney Jones, of St. Tho- 
mas's Hospital, London, by introducing setons 
of thread between the two. Instead of attempt- 
ing to create a fistulous opening between the 
ureters and the rectum, others, as Mr. Lloyd and 
Mr. Johnson, have endeavored to accomplish the 
same object by passing a stout seton of silk 
through the wall of the bladder and intermediate 
tissues into the rectum. 
These operations have not only failed to turn 
the urine into the bowel, but in the cases operated 
on by the last two surgeons named were followed 
by fatal peritonitis. 
Mr. Holmes has suggested a method of opening 
a communication between the bladder and the rectum by instrumental com- 
pression of the trigone vesical, between the ureters, until the tissues are de- 
stroyed by ulceration and sloughing. These procedures are all attended 
with considerable danger to life. If even the urine could all be successfully 
diverted into the bowel it is doubtful whether this would be the most satis- 
factory disposition that could be made of it. This opinion is based on the 
study of a patient who has been several times under my care, having a 
recto-vesical fistula, which allows a considerable portion of the urine to enter 
the rectum, where it is a source of great discomfort, although it can be 
retained for two or three hours at a time. . 
Dr. B. J. Levis, in a lad fourteen years of age, who was admitted into the 
Pennsylvania Hospital suffering from exstrophy of the bladder, attempted to 
relieve the deformity by first establishing a fistulous opening between the 
bladder and the perineum, which was done by introducing through both 
first a stout silk thread, and afterwards a soft, flexible bougie. A second 
operation was done some time after, with a view to cover in the anterior 
opening of the bladder by reflecting the integument from the scrotum and 
sliding it, with the cutaneous surface turned inward, beneath the integu- 
ment at the circumference of the opening, which had been dissected up for 
Fig. 1352. 
Urinal applied for exstrophy of 
bladder. 614 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
the purpose, and uniting the two by numerous sutures. The penis was also 
turned into the bladder. The urine was conducted from the bladder by 
a catheter introduced through the opening in the perineum. The patient 
died twelve days after the operation, from exhaustion produced by obstinate 
vomiting. 
Closure by Flaps.-This plan of supplying an anterior wall to the blad- 
der has been practiced at different times, and in some of its modifications 
promises results of a more practical character than any other operation 
which has as yet been devised. 
Among the first efforts for the relief of exstrophy by this method were 
those of Poux and of Richards, in 1853, in which two flaps were raised,-the 
one from the scrotum, and the other from the abdominal parietes above the 
opening. The disposition of these two flaps was not alike in the two opera- 
tions. In that of Roux, the scrotal flap was turned with its cutaneous surface 
inward, and attached above to the abdominal flap. In that of Richards, the 
abdominal flap was turned down with the skin inward, and its raw surface 
covered with scrotal flaps. 
Professor Joseph Pancoast, of Philadelphia, and Dr. Daniel Ayres, of Brook- 
lyn, New York, in 1853, each succeeded in closing in a case of exstrophy. 
In Dr. Pancoast's case, two flaps were raised, one from each inguinal re- 
gion, and brought together in the median line, where they were secured 
by sutures, the cutaneous surfaces being inward, in which position the raw 
surfaces gradually cicatrized. In Dr. Ayres's case, one flap was obtained 
from the umbilical region and turned down over the opening, its raw sur- 
face being external; to cover this, two additional tegumentary flaps were 
dissected from the sides of the abdominal walls contiguous to the exstrophy, 
and drawn together over the first. By this method no raw surface was left 
exposed. 
These were the first successful plastic operations for the relief of vesical 
exstrophy. 
Mr. Bryant, of London, has had successful cases of operation for exstrophy, 
the flaps being taken from the groin and from the scrotum, the latter being 
used to cover the raw surface of the former. Professor Wood, of King's Col- 
Fig. 1353. 
Fig. 1354. 
Lines of incision in Wood's method (from Ashhurst). 
lege, London, who has operated seventeen times fbr the relief of this malfor- 
mation, combines the methods practiced by Pancoast and by Ayres,-that is, 
a lid of integument is turned down from the abdomen above the opening 
with its skin surface inward, and this flap is covered by two others taken 
from the inguinal regions. (Fig. 1353.) Professor Ashhurst has repeated 
this operation in three cases, two of which were successful. 
Operation of Maury for exstrophy of bladder. THE URINE. 
615 
Dr. Maury, in two instances, dissected a largo convex flap of integument 
from the groin, perineum, and scrotum, and, after cutting a small slit, 
through which was slipped the penis, turned the flap upward, skin sur- 
face down, over the exstrophy. A short flap of integument was next raised 
from the upper and lateral portions of the opening, beneath which was slid 
the margin of the first flap, the two being connected by stitches similar to 
the tongue-and-groove suture of Professoi* Pancoast. This plan is a modi- 
fication of that of Roux. (Fig. 1354.) This procedure I practiced with a 
most satisfactory result in a child operated on before the medical class at 
the University Hospital, the cicatricial tissue by its contraction at the same 
time curing a double inguinal hernia which existed, a result which also 
followed in both of Maury's cases. Professor Bigelow, of Boston, dimin- 
ishes the extent of the mucous surface by denuding the posterior wall of the 
bladder of its lining membrane on a line with the ureters, using two flaps, 
one from each inguinal region, to covei' in the raw surface and the exstrophy 
below. 
No single plan of operation will meet the requirements of every case. The 
procedure of Ayres has the widest application, suited as it is alike to the male 
and to the female; though when the case is a male the operation as modified 
by Maury will often promise the most satisfactory result. After the adjustment 
of the flaps, the patient should be placed in a position which will cause as 
little tension as possible on the sutures,-that in which the trunk and thighs 
are well flexed. A water dressing, or a dressing of carbolated oil, will be 
best suited for covering the wound. The evils most to be apprehended are 
erysipelas and sloughing of the flaps. 
Of the value of these operations to patients suffering from exstrophy there 
can be no doubt. Although control over the urine is not secured, the flow 
is limited to a single point, rendering the adjustment of a urinal practica- 
ble, and thereby protecting the abdomen and limbs from contact with the 
water. 
The results furnished by these operations for exstrophy are quite en- 
couraging. Of 55 cases analyzed by Dr. Ashhurst, 43 recovered, 4 failed, and 
8 died,-a death-rate of only 14.6. 
The diseases which arise from functional and other disturbances of the 
kidneys demand a very careful study of the urine, in both its normal and 
its abnormal states. The urine is a very changeable secretion, and is much 
influenced by disease, injury, emotional causes, food, drink, exercise, and 
repose. 
Normal urine is of a light or yellow color, has a specific gravity of about 
1020, emits an unpleasant odor peculiar to the secretion, and yields a faintly 
acid reaction. The average quantity passed by an adult during twenty- 
four hours is about forty-five or fifty ounces. Considerable deviations from 
the above characteristics may exist without being incompatible with the 
normality of the secretion. Thus, a free use of water or other drinks, the 
action of diuretics, or a slight excitement of the nervous system will not only 
render the urine much lighter in color, but will also cause a marked increase 
in quantity ■with a lower specific gravity; or it may be diminished in its trans- 
parency by the accidental presence of an excess of mucus and epithelia, 
both derived from the genito-urinary tract. The same effect will be pro- 
duced by the formation of an undue amount of the earthy phosphates or urates 
in the secretion. The reciprocal action of the skin and kidneys, so well un- 
derstood by physiologists, materially affects both the color and the quantity 
of the urine. Thus, during the heat of summer, when the sensible perspira- 
tion from the glandular apparatus of the skin is increased, thereby diminish- 
ing the watery constituent of the secretion, the urine is darker in color and 
less in amount than in winter. Certain substances when taken into the 
The Urine. 616 
INJURIES AND DISEASES OF THE GEN1TO-URINARY ORGANS. 
stomach and subjected to digestion impart a peculiar color to the water: 
thus, the internal use of santonin renders the urine yellow. 
The odor of urine is also modified by the internal use of certain medicinal 
substances, as the turpentines, cubebs, and copaiba; or by different articles 
of food, as asparagus, onions, etc. 
Reaction.-The acid reaction, which for the whole quantity of the twenty- 
four hours' urine is quite constant, may be temporarily changed by the 
process of digestion, becoming after a full meal alkaline or neutral, either in 
consequence of the amount of alkaline principles contained in the food, or, 
as others suppose, from the extraordinary demands made on the blood by the 
gastric juice at this time, by which the acids of the body are for a time 
diverted from the renal secretion. 
Composition.-The urine consists of various organic and inorganic sub- 
stances dissolved in water. The latter amounts to about nine-tenths of the 
whole, or 933 parts in 1000. 
The organic matters are derived from the destructive or retrogressive 
metamorphosis of the tissues of the body, and from the food during its prep- 
aration and assimilation. The most important of these substances to the 
surgeon are urea and uric acid. The less important consist of creatine, crea- 
tinine, and lactic and hippuric acids, the last two being formed from the food 
during its assimilation. The inorganic constituents of urine are both saline 
and mineral. They exist as phosphates, sulphates, and chlorides, formed by 
the union of their respective acids with bases of potash and soda. The bases 
of the mineral salts are, for the most part, lime and magnesia. In addition 
to the above ingredients there are others which are derived from the urinary 
passages, as mucus-corpuscles, and renal and vesical epithelium. 
Pathological Changes.-When there is present in the urine an abnormal 
amount of urates, as soda, lime, potash, and magnesia, though they may 
not appear at the time the secretion is voided, they will be precipitated as 
the temperature of the urine is lowered, rendering it thick, muddy, and 
turbid, and leaving a pink deposit or crust adherent to the containing ves- 
sel. The nature of this deposit can readily be determined by the addition 
of heat, on the application of which the urates are quickly redissolved and 
held in suspension by the watery part of the urine. This state of the urine 
is often witnessed in persons suffering from indigestion and fever, or from 
rheumatic and gouty attacks. 
In other instances the deposit may be made up of phosphates of lime and 
magnesia. These finally settle to the bottom of the vessel, forming a heavy 
and cloudy deposit, and may readily be confounded with a deposition of 
mixed urates. The distinction, however, can be established without diffi- 
culty by either the application of heat or the addition of a little nitric acid 
to the urine. The sediment, if it consists of phosphates, will quickly clear 
up on the addition of the acid, but will be increased by heat. 
The urine may also be rendered opaque by the presence of pus, by an 
undue amount of mucus, or by both. When pus alone exists in the secretion, 
it subsides quickly to the bottom of the vessel, leaving the supernatant liquid 
clear; but if mingled with mucus, buoyed up by the latter it will float for a 
long time in the urine before settling as a deposit, thus rendering the water 
cloudy or opaque for a considerable period. By the addition of heat, how- 
ever, this cloudiness may readily be distinguished from the turbidity result- 
ing from a redundancy of urates, for instead of clearing up, as in the latter 
condition, the opacity will become more dense from coagulation of the 
albumen contained in the pus liquor. 
In chronic cystitis muco-pus constitutes the leading characteristic of the 
urine. Not only so, but it imparts to the latter a viscid, ropy consistence, 
resembling a thick decoction of flaxseed-tea. 
The density of the urine has been stated to be about 1020, but is subject to 
great variations. When containing much albumen, as in Bright's disease of 
the kidneys, the specific gravity is diminished, except in the acute stage, THE URINE. 
617 
when the presence of blood tends to make it higher. In diabetes mellitus 
the density is signally increased, reaching in some cases as high as 1040 or 
1050. In the early stage of all acute fevers the specific gravity is also in- 
creased, and the same is true when there is an unusual activity of the cuta- 
neous glands, as in sweating or after violent exercise. In all these conditions 
the increased density is to be attributed to destructive metamorphosis of the 
tissues increasing the amount of urea in the secretion. The specific gravity 
of urine is determined by the urinometer (Fig. 1355), an instrument which, 
though not absolutely correct in its registra- 
tion, is sufficiently accurate for all practical 
purposes. 
In using this little instrument, the urine 
should be placed in a tall, narrow, glass vessel, 
and the urinometer floated in the liquid. (Fig. 
1356.) The depth to which it sinks will be 
indicated by the figures on the scale, and the 
specific gravity may be ascertained by adding 
this number to 1000, which stands for unity. 
As the urinometer has been graduated at 60° 
Fahr., the urine should have the same tem- 
perature to make the instrumental examina- 
tion accurate. 
In ascertaining the specific gravity of urine, 
we also obtain approximately the amount of 
solid matters which the secretion contains by 
multiplying the number above 1000 by 2 for 
all densities under 1018, and for all above 
1018 by 2.33. For example, in a specimen of 
urine the specific gravity of which was 1015, 
there would be 30 grains of solid material in 
the 1000 grains of urine. If the specific 
gravity of another specimen amounted to 
1020, there would be in the 1000 grains 46.66 grains of solid matter. 
Quantity of urine.-As already stated, the average amount of urine passed 
in twenty-four hours has been fixed at forty-five or fifty ounces in health ; 
but great fluctuations from the normal standard are observed in disease. 
The most remarkable example of an increased quantity is witnessed in 
diabetes mellitus, when several gallons may be discharged in the twenty-four 
hours. In hysterical and other convulsive affections, also, the amount ex- 
creted is far above the average. 
Whatever tends to obstruct the portal venous circulation, as disease of the 
heart or of the liver, will, by increasing the blood-pressure in the kidneys, 
contribute to an increase in the amount of the urine. In shock, in diarrhoea, 
in exhaustion, in the sweating of hectic, in Bright's disease, particularly in 
its advanced stage, in dropsy, in contracted and in albuminoid kidney, and 
in all acute forms of fever, the urinary secretion is diminished in quantity. 
Frequency of urination is a very constant attendant of all diseases affecting 
the bladder or the kidneys, though there is not in such cases necessarily any 
increase in the amount voided during the twenty-four hours. 
Odor.-The usual urinous or so-called aromatic odor of urine is frequently 
changed from pathological causes. When the urine is saccharine, it often 
emits a sweetish odor; when it deposits the unusual sediment of cystine, it 
may have the smell of sulphuretted hydrogen ; and in most cases of cystitis 
arising from spinal injury, paralysis, stone, or prostatic disease, there is very 
commonly both an ammoniacal and a putrid odor,-the result in the first case 
of the ammonia liberated in the decomposition of urea, and in the last of the 
decomposition of the abundant mucus derived from the mucous membrane 
of the bladder. 
Reaction.-Healthy urine being usually acid, it will redden blue litmus- 
Fig. 1356. 
Fig. 1355. 
Urinometer. 
Urinometer introduced 
into a glass containing 
urine. 618 
INJURIES AND DISEASES OF THE GENITO- URINARY ORGANS. 
paper. The acidity of the secretion is probably due to the combined effects of 
several of its acid constituents, as uric, lactic, and hippuric acids, and chiefly 
the acid phosphate of soda. The fluctuations in the reaction of urine from 
the effects of food and digestion have been already noticed. The acidity of 
urine is increased by both mineral and vegetable acids, as the nitric, sulphuric, 
tartaric, etc., etc. A similar increase will be found to exist when the functions 
of the cutaneous glands have been lessened or suppressed, inasmuch as an 
additional amount of acid substances, as butyric, formic, propionic, and sudoric 
acids, and urea, which should normally escape by the perspiration, is com- 
pelled to find its way out of the system through the renal organs, which in a 
great measure are obliged to provide for the failure of the skin to do its duty. 
Whatever interferes with the digestion of the food, producing sour eructations 
and flatulence, will intensify the acidity of the urinary secretion, as will any 
interference with the proper disposition of the products of tissue-change: 
hence the acidity of the urine in rheumatic and gouty diseases. Urine which 
has stood for some time in a vessel, though acid at the time of being voided, 
will after a short time become alkaline. An elevated temperature conduces 
to, or rather hastens, such change, the result being brought about by the 
mucus and other organic substances playing in their decomposition the part 
of a ferment, and converting the urea into carbonate of ammonia, a change 
which may take place both in and out of the bladder. 
The introduction of blue litmus-paper into a specimen of urine will, if the 
latter is alkaline, be followed by no change in the color of the paper. The 
cloudy state of the urine which is frequently witnessed when the secretion 
is alkaline arises from the precipitation of the earthy phosphates by the 
presence of either a fixed or a volatile alkali, or of both at the same time. 
When the deposit is amorphous, it has been determined by the fixed alkali, 
and consists of the phosphate of lime; when crystalline in character, it is due 
to the volatile alkali, as the carbonate of ammonia forming the phosphate 
of ammonia and magnesia. In such urine a greasy or iridescent scum or 
pellicle is occasionally seen floating on its surface. 
The morbid conditions which are actively concerned in imparting alkalinity 
to the renal secretion are dyspepsia, injuries of the spine, paralysis, etc. 
Albumen.-Among the organic constituents of urine albumen is frequently 
found, and its presence is always very significant, awakening usually the 
anxiety of the physician, and leading him to a careful examination of the 
organs of the body. Albumen appears in the urine abundantly in Bright's 
disease of the kidneys; during the latter months of gestation in the female; 
in dropsical affections; in pneumonia; sometimes in traumatic and other 
fevers, and also during the course of other diseases. 
The recognition of albumen is accomplished by the tests of heat and nitric 
acid. 
The heat test is made in the following manner. Fill an ordinary glass test- 
tube about one-third full of urine, and apply heat from a gas-jet or by means 
of a spirit-lamp. If the contents of the tube become cloudy, or somewhat 
opaque, it will be due to the presence of a deposit either of earthy phosphates 
or of albumen, which may be quickly determined by the addition of a few 
drops of nitric acid, when, if the opacity is due to phosphates, it will rapidly 
disappear, and if caused by albumen it will be increased. Should the urine 
at the time of its being subjected to this test prove to be alkaline, the addi- 
tion of a few drops of acetic acid, and then boiling the fluid, will be a proper 
preliminary measure to the experiment. Urates and albumen may exist in 
the same specimen of urine. When the heat is applied, the amorphous urates 
will be quickly redissolved, after which the albumen will bo deposited. 
Nitric acid constitutes a very delicate test for albumen. The method of 
Heller is the one best adapted for this purpose. By this plan a small quantity 
of nitric acid is introduced into a glass test-tube, and when the latter is inclined 
to one side, the same amount of clear urine is allowed to trickle down the 
side of the tube, a drop at a time, discharged from a pipette. As the two THE URINE. 
619 
liquids come in contact, in the urine on top of the acid there will appear, if 
albumen is present, a white stratum or zone. As a white cloud may form, 
when there exists an excess of mixed urates in the urine, on the application 
of this same test, it is proper that the true nature of this deposit be recognized. 
This knowledge is most satisfactorily obtained by adding heat to the urine 
in which the white band appears, when, if dependent on amorphous urates, 
it will quickly clear up; if on albumen, the reverse will be the case. Urine 
containing albumen has a low specific gravity. 
Pus is frequently found in urine, and may be derived from any portion of 
the genito-urinary tract. When the quantity is considerable, it settles to the 
bottom of the liquid, forming a white, opaque, or yellowish sediment. In 
the event of much mucus existing in the water along with the pus, the latter 
remains for a long time suspended by the former. It is possible, on a simple 
inspection of urine, to confound the deposit of pus or muco-pus with urates. 
Any mistake of this kind may be corrected by applying heat, which will re- 
dissolve the deposit, if consisting of urates, and restore the urine to its origi- 
nal clearness; but if the sediment is formed of pus, the albumen of the liquor 
puris will be deposited, and thereby increase the cloudiness of the liquid. 
Amorphous phosphate of lime also bears some faint resemblance to pus, 
but nitric acid will clear up any opacity from this substance, while it will 
increase that arising from pus by precipitating its albumen. 
The diagnosis of purulent urine has been based upon its behavior with 
alkalies, as the liquor potass®, which, when added to the deposit of pus, after 
the urine has been poured off, will form with it a tenacious, viscid, or gela- 
tiniform substance, which pertinaciously adheres to the bottom of the vessel, 
even when the latter is inverted. This is Donne's test. The microscope 
furnishes the most satisfactory evidence of the presence of pus. (Fig. 1357.) 
Pus in the urine is generally an 
indication of some serious trouble in 
the kidney, the bladder, the prostatic 
body, or the urethra. It is not always 
an easy matter to designate the exact 
source of the fluid. When derived 
from the kidney, the ordinary acid 
reaction of the urine will remain un- 
changed, in consequence of the ab- 
sence of mucus, which is so actively 
concerned in the production of fer- 
mentation; but when formed in the 
bladder it is soon associated with an 
alkaline state of the urine. 
The acid reaction of the urine will 
be retained also when the pus origi- 
nates in the urethra and prostate 
body, provided cystitis does not exist. 
When derived from the prostate, 
the pus-cells not unfrequently are 
arranged and connected with one 
another in a linear or thread-like form, 
and may be seen floating in the urine. Pus is always found in the renal 
secretion in cases of nephritic calculus, nephritis, cystitis, prostatitis, and 
urethritis. Pus may be altogether accidental to the urinary secretion, being 
derived from the vagina or the ureters in the female, or from a perineal or 
urethral fistula. 
Blood may enter the urine from the same sources as pus. The appearance 
presented will depend on the amount of the fluid contained in the secretion. 
It imparts to the urine a reddish or a brown, smoky hue, quite characteristic. 
The microscope will always resolve any doubt entertained by the surgeon, 
by revealing the blood-corpuscle, when it exists in the urine. The color, it is 
Fig. 1357. 
Corpuscles of pus: those at the lower part of cut, 
acted on by acetic acid. 620 
INJURIES AND DISEASES OF THE GENITOURINARY ORGANS. 
proper to say, is influenced by the reaction of the urine, being red in alkaline 
and dark in acid urine. 
In order to trace the blood to its proper source, attention must be given to 
the form of the accumulation. When in clots, it probably has an origin not 
higher than the bladder; when equally diffused through all parts of the 
water, its renal origin will be highly probable; and when discharged in the 
form of small cylinders, the posterior portion of the urethra most likely sup- 
plies the blood, which becomes moulded to the shape of the canal as it slowly 
escapes from the vessels. 
Epithelium.-There are three forms of epithelium met with in the urine,- 
the round, the squamous, and 
the cylindrical. (Fig. 1358.) 
The round and the cylin- 
drical, or columnar cells, exist 
in all parts of the genito- 
urinary tract, from the infun- 
dibula of the kidney to the 
urinary meatus. The squa- 
mous are confined chiefly to 
the mucous membrane of the 
bladder. In all inflammatory 
diseases of the mucous lining 
of the urethra, bladder, ure- 
ters, and kidneys, the attend- 
ant desquamation furnishes 
an abnormal amount of epi- 
thelium to the urine, though, 
unless associated with other 
symptoms, it is impossible to 
recognize the exact part of the 
extended mucous membrane 
from which they have been 
detached. These cells can 
be distinguished from the 
pus-corpuscles by the single 
nucleus which they contain, 
whereas the pus-cell has several, and requires for their exposure the addition 
of a little acetic acid. 
Tube-casts are formed by a fibrinous transudation or extravasation into the 
uriniferous tubes from the contiguous vessels. This transudation, coagulating 
and incorporating with it epithelial cells, blood, etc., assumes the form of the 
tubule in which it lies; and when expelled into the ureter it passes into the 
bladder as a cylindrical cast. These plugs are distinguished as epithelial, 
granular, fatty, and blood casts. 
The epithelial cast (Fig. 1359) consists of renal epithelia, either imbedded 
in a fibrous transudation or simply aggregated together and assuming the 
form of the uriniferous tubule. 
The granular cast (Fig. 1360) is made up of the particles resulting from a 
disintegration of epithelial cells or blood-corpuscles. 
Fatty casts (Fig. 1361) are those which contain chiefly oil, both in the 
epithelium and in a free state. 
Blood-casts may contain little else than blood-corpuscles united together by 
fibrogenous substances. 
Hyaline casts present different appearances according to their composition. 
When made up of fibrin without epithelial cells, they exhibit a homogeneous 
and transparent appearance; when containing a few oil-drops, they present 
here and there yellowish points ; and when more consistent, and having the 
appearance of melted wax (Fig. 1362), they constitute the variety termed 
waxy casts. 
Fig. 1358. 
a, round epithelium from bladder. 
b, columnar epithelium from ureter and urethra. 
c1, columnar and squamous epithelium from deeper epithelial 
layers of bladder. 
c2, squamous epithelium from superior layer of epithelium of 
vagina. THE URINE. 
621 
The significance of these tube-casts is quite important, indicating serious 
disease of the kidney, and often contra-indicating surgical operations. The 
Fig. 1359. 
Fig. 1360. 
Tube-casts in acute desquamative nephritis- 
Bright's disease. 
Granular tube-cast. 
fatty and hyaline casts are found in their most typical forms in Bright's 
disease of the kidney. The waxy hyaline casts, though seen to some extent 
in both acute and chronic Bright's disease, greatly exceed all others in the 
Fig.1361. 
Fig. 1362. 
Fatty cast. 
Hyaline waxy cast, with epithelial cells from the 
bladder. 
wax kidney, a disease which generally is much less rapid in its progress 
than that known as Bright's. Granular casts belong more especially to the 
granular or contracted kidney, and are not present in the early or acute 
stages of the renal diseases. 
Spermatozoa are frequently found in the urine. These cells possess an 
elongated head attached to a long filament. (Fig. 1363.) They enter the 
urethra along with the semen, and are washed out during urination. They 
may even reach the bladder and mingle with the urine before it has been 
passed from that viscus. When present in large numbers, together with 
spermatic fluid, they impart a slightly cloudy appearance to the urine. 
They are easily detected by the microscope with a power of 400 diameters. 
Their presence generally indicates a capacity for fruitful intercourse when 
not associated with sexual impotence. 622 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
These bodies may be detected in the stains on the linen of masturbators 
by soaking it in a little water for a short time and afterwards examining 
the solution microscopically. 
Sugar in the urine is another symptom of the gravest 
import. The high specific gravity alone of the secretion 
(1030) will be sufficient to awaken a suspicion of its 
existence. If to this is added a very large increase in 
the quantity of the water, with urgent thirst, its presence 
will be still more probable. 
Saccharine urine, however, may be positively demon- 
strated through the agency of certain tests, of which 
there are a great number. Five may be mentioned,- 
namely, the copper or Trominer's test, the bismuth or 
Boettger's test, the fermentation test, the Moore test, and 
the Heller test. 
Copper test.-To the specimen of urine to be examined 
add a few drops of a solution of sulphate of copper (one 
part of the sulphate to thirty parts of water), and after- 
wards liquor potassae in excess, or an amount equal to 
half the volume of urine under inspection. The effect 
of adding the liquor potassae is to liberate a hydrated 
protoxide of copper, and by continuing to add the alkali, if sugar is present, 
the precipitate will be redissolved, leaving a blue, transparent fluid. That 
the test may be more conclusive, let the mixture in the glass tube be boiled, 
when, in the event of the urine being saccharine, an abundant yellow pre- 
cipitate will be deposited, consisting of the hydrated suboxide of copper, 
which after a time becomes, by the loss of its water, the red suboxide of 
copper. To give additional certainty to this copper test, a second mixture, 
prepared as described, should be set aside, without boiling, for several hours, 
when, if sugar is present, a similar precipitate of the red suboxide will follow. 
The experiments of Dr. George Hay, of Alleghany, Pennsylvania, in common 
with those of other writers, have shown that, under certain conditions, the 
copper test cannot always be relied on, as when there are present in the urine 
certain compounds of ammonia, as the chloride and the urate, which defeat 
the reduction of the oxide of copper and thus render the examination un- 
reliable. Another precaution must be observed in testing the urine for sugar, 
-namely, to get rid of any albumen which may exist in the secretion. 
Bismuth test.-Add to the urine to be examined an equal amount of liquor 
potassae, then a small quantity of subnitrate of bismuth. Shake the mixture, 
then boil it for two or three minutes. If sugar is present, there will be 
deposited on the sides of the test-glass a black powder (metallic bismuth), 
produced by the property possessed by sugar of reducing the salts of bismuth 
to the metallic state. The caution to be employed in this test is not to use 
any excess of bismuth, a few grains being sufficient. 
Fermentation test.-This is the most troublesome, but also the most reliable, 
of all tests for sugar. Into a large-sized test-tube provided with a cork 
stopper, through which is passed one branch of a bent glass tube reaching 
to the bottom, introduce one drachm of brewer's yeast, and fill up the tube 
with urine. Then, introducing the stopper, place the apparatus in a vessel 
containing lukewarm water, and set it aside in a room in which the tem- 
perature is about 70° Fahr. If the liquid contains sugar, in the course of 
twelve hours fermentation will commence, and the disengagement of car- 
bonic acid gas will force the liquid out through the bent tube. Saccharine 
urine is frequently noticed in cases of gangrene of the feet. 
Moore's test.-Placing a small quantity of urine in a test-tube, add to the 
same about half the quantity of liquor potassae, and boil. If there is any 
sugar present in the liquid the latter soon becomes of a yellowish-brown color, 
which deepens in tint as the boiling progresses, becoming finally almost black 
when the urine is rich in sugar. This test is based on the fact that, grape 
Fig. 1363. 
Spermatozoa. URINARY DEPOSITS. 
623 
sugar and diabetic sugar being identical, the saccharine matter undergoes 
oxidation when boiled with caustic alkali, the oxygen being derived from the 
air. The dark coloration is produced by the glucic and melassic acids. 
Heller's test, which is a modification of the above, consists in adding a few 
drops of nitric acid to the colored fluid produced in Moore's test, the effect of 
which is to destroy the dark coloration, at the same time developing the odor 
of burnt molasses. 
In all the tests where solutions of potash or soda are employed, the liquids 
should be kept in green glass bottles, as when preserved in flint-glass bottles 
they are liable to become impregnated with lead, the action of which, when 
boiled with organic matter containing sulphur, is to produce a brown color 
from the formation of sulphuret of lead. 
Bile in the urine may be suspected wdien the secretion has a yellow color, 
or when it imparts a yellow stain to a piece of linen moistened in the fluid. 
To render the recognition certain, the tests of Gmelin should be employed. 
The first is the nitrous acid test, and the simplest manner of using it is to place 
a few drops of urine on a porcelain plate, and close alongside a like quantity 
of fuming nitric acid. The gradual intermingling of the two liquids is fol- 
lowed, if bile is present, by a play of colors.-green, blue, violet, red, and 
yellow. 
Whenever any important operation is contemplated, it is a very wise pre- 
caution to subject the urine to a careful preliminary examination, and if it 
is found to contain albumen, casts, sugar, or bile, the utmost care should be 
exercised in the management of the case. 
Normal urine, when fresh, furnishes no deposits except a little mucus, 
with a few epithelial cells, which, as the liquid cools, subsides. Yet even 
normal urine, when exposed to the air, will undergo, in the process of fer- 
mentation, such changes as give rise to deposits of different kinds. 
Among these may be noted amorphous granular substances composed of 
acid urates, such as potash, soda, and ammonia, all of which are soluble by 
means of heat. The most common organic constituents of the urine concerned 
in determining depositions are uric acid and urea. 
Uric Acid is an extremely insoluble substance, one part of the acid re- 
quiring 1800 parts of hot water to dissolve it. It constitutes a very small 
proportion of the urine,-about one grain in 1000 grains of urine. The uric 
acid deposits may appear as a lateritious sediment of yellowish or red sand 
or gravel, consisting of variously-shaped crystals not inaptly compared to 
particles of cayenne pepper, which adhere as a crust to the vessel in which 
the urine has been allowed to stand. The presence of uric acid is associated 
with a very decided acidity in the reaction of the urine. It is the most 
common constituent of vesical calculi: hence its synonym Zit/uc acid. 
The crystals of uric acid have various forms, as rods, squares, plates, com- 
pact bundles of needles, though the prevailing forms are lozenge- or rhomb- 
shaped (Fig. 1364), and are of a pale straw-yellow or orange-red color. They 
constitute, in combination with potash, soda, magnesia, lime, and ammonia, 
the deposits known as urates. 
Tests.-Both uric acid and the urates may be discriminated by the appear- 
ances which follow the addition of a drop or two of nitric acid to a deposit 
containing these substances, placed on a porcelain plate, and then evaporated 
over the flame of a spirit-lamp. A drop or two of liquor ammonite added to 
the residue brings out a beautiful purple hue. This appearance is believed 
to result from the formation of alloxan, allantoin, and ammonia. 
To distinguish between uric acid and the urates, however, requires the use 
of the microscope. 
Urates.-The urates constitute the great bulk of all urinary deposits, the 
most common being the urate of ammonia and the urate of soda. They 
Urinary Deposits. 624 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
appear as an amorphous sediment (Fig. 1365) having a variety of colors,- 
pale red, pink, yellow, etc. 
The urine from which these deposits are precipitated has a specific gravity 
Fig. 1364. 
Fig. 1365. 
Uric acid crystals. 
Amorphous urates. 
either slightly under or slightly over the normal standard, in color resem- 
bles pale sherry wine, has a strongly acid reaction, is not materially increased 
in quantity, and when voided is quite clear. 
Causes.-The uric acid deposits result from a rapid waste of the tissues, 
such as accompany a high grade of inflammatory or acute disease. 
In gout and rheumatism they appear particularly when the climax has 
been attained and these diseases begin to decline. Theii- presence at this 
juncture has procured for them the reputation of being critical. 
Defects in the process of digestion, either in the preparation of ingesta in 
the stomach and small intestine, or in the work of assimilation, and an excess 
of nitrogenized food, together with inactivity of the cutaneous excretions, 
are fruitful sources of the accumulation of uric acid in the blood. The brick- 
dust and fawn-colored deposits are believed by some to arise from this cause. 
Hence these deposits are often witnessed in the urine of sedentary or indo- 
lent persons who suffer from dyspeptic symptoms and who eat freely of 
animal food. 
The consumption of oxygen and carbon which occurs in respiration is not 
without an important influence, independent of blood-aeration, in preventing 
the deposits under consideration, by using up the materials which other- 
wise would go, in combination with urea, to form objectionable products. 
Whatever, then, tends to lower or embarrass the respiratory function will, 
it is believed by those who have carefully studied this subject, increase the 
uric acid of the urine. 
Disturbance of the functions of the liver, which consumes a large amount 
of carbon in the disposition of the fatty substances of the food, may also 
conduce to the same result much in the same way. It is to this cause that 
Dr. Golding Bird ascribes the presence in the urine of the pink, crimson, 
and purple deposits. In all liver affections there is usually a deposition of 
uric acid with amorphous urates. Especially is this noteworthy in malignant 
diseases of the organ, in which, as compared with those of a benign oi* non- 
malignant nature, particularly in their latter stages, the uric acid is in great 
excess,-a fact which is not without its value from a diagnostic point of 
view. The kidneys also, when their eliminative function has been dis- 
turbed by disease or injury, contribute largely to the production of the same 
deposits. 
In fine, everything which tends to interfere with the proper arterialization URINARY DEPOSITS. 
625 
of the blood tends also to increase uric acid, by diminishing the urea, through 
the combination of the latter with oxygen and carbon. 
Treatment.-In the treatment of the uric acid diathesis the true cause of 
the disease must be carefully sought. The great indications are, to regulate 
the diet so as to exclude all nitrogenized articles of food, and so as to aid 
stomachic and intestinal digestion, thus securing as much as possible the 
consumption of those materials which, if allowed to accumulate in the blood, 
tend to ally themselves with urea. 
These indications will be fulfilled by regulating the food both as to quality 
and as to quantity. Whatever has been found in the experience of the 
patient to cause acid eructations and flatulence must be interdicted. Animal 
food of all kinds is to be used sparingly, and should always be prepared either 
by roasting or by broiling. Fats, oily dressings, hot cakes, fresh bread, pastry, 
butter, sugar, sweet potatoes, and onions must be avoided. Instead thereof 
the patient may be allowed stale bread, soda biscuit, rice, milk, eggs, tea, ripe 
fruits, celery, tomatoes, and white potatoes. Alcoholic drinks must be for- 
bidden ; but, if stimulus has been rendered necessary by previous habits, a 
little whisky may be allowed at dinner. 
The second indication will require for its fulfillment the restoration as far 
as possible of the proper functional activity of all the organs of the body 
which are prominently concerned in the work of secretion and excretion. 
The bowels are to be kept in a regular state, which will be best secured by 
the occasional use of a little blue mass at bedtime, and in the morning follow- 
ing, three-quarters of an hour before breakfast, of two or three drachms of 
the sulphate of soda largely diluted with water. 
Daily exercise in the open air on horseback, or, what is better, on foot if 
the strength will allow, is of the first importance. An active out-door life 
improves the respiration, increases the action of the skin and kidneys, and 
secures the oxidation of those products which result from the retrograde 
metamorphoses of the tissues. The large amount of solid matters which 
find their way out of the system through the glandular apparatus of the skin 
renders it desirable to keep this emunctory in the best possible condition 
for executing the task of elimination, which will be materially promoted by 
tepid bathing and frictions, and by proper care in clothing. Attention to 
the above instructions cannot fail to exert a great influence in correcting 
this disease. 
The medicinal treatment should be directed to the removal of hyperacidity 
and the improvement of the general health, for which objects a combination 
of alkalies and tonics is required. 
Among the best agents of this kind is the compound infusion of gentian, 
with the bicarbonate of soda or potash, and the tincture of nux vomica. 
If alkaline remedies are contra-indicated, those acid salts which, in passing 
through the system, are converted into alkaline carbonates, may be substi- 
tuted, as the citrates, acetates, or tartrates. Iron and quinine may be de- 
manded when the patient is weak and amemic; and when there is great 
irritability of the urinary organs, with restlessness and wakefulness, opium, 
in the form either of Dover's powder or of morphia, will often be pro- 
ductive of the happiest effects. Among the mineral waters in common use, 
none is better adapted to the diathesis under consideration than Vichy 
water. 
Oxalate of Lime.-Oxalic acid, when existing in the urine, is found in 
combination with lime in two crystalline forms,-the octahedral and the 
dumb-bell. (Fig. 1366.) Though not forming a noticeable deposit, these 
crystals are often found entangled in the mucus which is seen floating in the 
urine. 
The octahedral crystals when viewed with the microscope resemble (when 
seen in their long diameter) two quadratic pyramids with well-defined angles 
and with their bases applied against each other. Viewed in another posi- 
tion, these crystals exhibit a flattened or square figure. The dumb-bell variety, 
vol. ii.-40 626 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
much less common than the other, conforms in shape very accurately to 
the object after which the crystals are named. The mass resulting from a 
conglomeration .of these bodies fre- 
quently constitutes the nucleus of a 
stone. 
The only two deposits with which ox- 
alate of lime is likely to be confounded 
are certain of the triple phosphates 
and uric acid. Any doubt, however, 
which may arise on this subject can 
be readily removed by adding to the 
sediment a little acetic acid, when, if 
the deposit is made up of phosphates, 
the latter will be quickly dissolved; 
a solution of caustic potash will cause 
any uric acid which may be present 
to disappear: neither of these tests 
affects the oxalate of lime. 
The manner in which oxalic acid is 
formed in the system and appears in 
the urine is undetermined. Some, as 
Bocker, assert that it is a normal con- 
stituent of the body. Schunk endeavors to show that it is formed from 
the oxalate of ammonia during the decomposition of urine, though Neu- 
bauer alleges that the decomposition of this substance, instead of producing 
oxalic acid, results in the formation of carbonate of ammonia. Prout refers 
the origin of oxalic acid to the imperfect digestion of saccharine vegetable 
matter. Rhubarb, sorrel, and other members of the vegetable kingdom are 
quite rich in this substance. Others, and among them Frerichs, assert that 
this acid is formed by the decomposition of uric acid and urates. There is 
reason to believe, from observations which have been made by experimenters, 
that oxalic acid may be derived not only from all the three groups of food 
(namely, the albuminoid, the fatty, and the saccharine), but also from the 
retrograde metamorphosis of various animal substances in the body. Oxa- 
late of lime, or oxaluria, as the disease is often termed, .is more common in 
men than in women. The symptoms which indicate the existence of this 
diathesis are of a dyspeptic character, as flatulence, fullness in the epigas- 
trium, oppression on the chest, eructations of gas, and palpitation of the 
heart. 
The nervous system is often profoundly implicated in the disorder; the 
patient becomes depressed in spirits, gloomy, hypochondriacal, often fretful, 
loses all interest in business, and is disqualified for any active employment. 
The sexual power is impaired, and in some instances entirely lost; frequent 
micturition may exist, and is attended with some heat, and probably with 
more or less scalding, while the patient steadily loses in flesh. Unless the 
condition of oxaluria is early recognized and corrected, it will result in the 
formation of calculus, and that of an exceedingly painful kind. 
Treatment.-As oxaluria is closely associated with irregularities in the 
digestive organs, attention must be first given to a strict regulation of the 
diet. All vegetables and fruits containing oxalic acid must be avoided, as 
rhubarb and tomatoes; also those which are rich in malic, citric, or tartaric acid. 
All wines are to be eschewed, also beer, ale, and porter: if any stimulants are 
required, whisky or gin will be the least objectionable. Water containing 
lime is unfit to be used by a patient laboring under oxaluria, as it furnishes a 
ready basis for combination with oxalic acid. In limestone districts, in which 
the drinking-water is hard, it may be improved by boiling, though still objec- 
tionable, and it will be better to direct the use of distilled water, the insipidity 
of which may be removed by the addition of a little gin. 
Attention to out-door exercise, to the condition of the skin, and to the 
Fig. 1366. 
Crystals of oxalate of lime. URINARY DEPOSITS. 
627 
correction of any pulmonary, circulatory, or renal disorder, is as important 
in the general management of oxaluria as in the uric acid diathesis. 
The tonics which have been found most useful in this disease are the 
mineral acids, as the nitric or the nitro-muriatic, and when these fail to 
make the requisite impression on the deposit, the acid phosphate of soda 
may in some instances be advantageously substituted. 
Phosphatic Deposits.-Phosphoric acid is not found in the urine in a free 
state, but combined with alkaline and earthy bases. The alkaline bases are 
potash and soda, and the earthy bases lime and magnesia. Urine which is 
healthy contains very much more (about four times) of the alkaline than of 
the earthy phosphates. The deposition of phosphates spontaneously from 
normal urine does not occur, they being kept in solution. When, however, 
the secretion is exposed for a time to the air and fermentation commences, 
the decomposition of its urea into carbonate of ammonia begins, and crystals 
of the triple phosphates are precipitated, consisting of the ammoniaco-mag- 
nesian phosphates and the phosphate of lime. 
The alkaline phosphates, namely, the phosphate of soda, the acid phosphate 
of soda, and the phosphate of soda and ammonia, being very soluble, do not 
occasion deposits. 
The spontaneous deposit of phosphates in fresh urine is no evidence that 
there is an undue elimination of these matters. Indeed, it may be evidence 
of the reverse condition. If the urine happens to be alkaline, the earthy 
phosphates, being insoluble in the secretion having such a reaction, are im- 
mediately precipitated; but if the reaction of the urine proves to be very acid, 
both the alkaline and the earthy phosphates may exist in great excess and yet 
no deposition occur. This fact should never be overlooked in examinations 
of urine. 
These earthy phosphates are all quite insoluble in water, but soluble in 
acids. Heat will cause their precipitation. In this respect they resemble in 
behavior albumen, with which they are sometimes confounded. The addi- 
tion, however, of a little acid, as nitric or acetic, soon dispels the delusion by 
rapidly dissolving the deposit, which would not occur if the turbidity was 
due to albumen. To ascertain approximately the amount of the earthy 
phosphates in a specimen of urine, it is only necessary to add a few drops 
of ammonia, when a light-colored precipitate will be thrown down, and one 
which will not be redissolved by heat. 
The phosphatic deposits include three varieties, namely, the phosphate of 
lime, the triple phosphate of magnesia and ammonia, and the mixed phosphates, 
or those containing both the phosphate of lime and the triple phosphate. 
1. Phosphate of lime, that is, the earthy phosphate, may appear either as 
an amorphous powder or in crystalline form, depending on the degree of ra- 
pidity with which the phosphate is precipitated, viz., rapid in the first and 
slow in the last form of deposit. The color of the sedimentary matter is 
whitish or gray. The crystalline portions exhibit prismatic, rosette, and 
spherical forms; the latter may, on a careless inspection, be mistaken for 
dumb-bells, because when two of these globules adhere, a slight constriction 
will be noticed at the point of conjunction. 
2. The triple or ammoniaco-magnesian phosphate appears as a deposit of 
minute white crystals. (Fig. 1367.) Other forms are also noticed, as fronds 
or feathers, disposed in stellate figures. This is the case particularly when 
the crystallization takes place rapidly, as when it is induced by the addition 
of ammonia to the urine immediately after its passage. 
The iridescent film which is often seen floating on the top of the urine is 
made up of these crystals, with other products of the decomposing secretion. 
Urine containing these triple phosphates is usually pale, with a low specific 
gravity, and somewhat increased in quantity above what is normal. 
3. Mixed phosphates are those which consist of a combination of the phos- 
phate of lime and the triple or ammoniaco-magnesian phosphates. The 
urine when thus constituted is abundant and pale, emitting an offensive 628 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
odor, and mixed very often with a quantity of ropy, vesical mucus, throwing 
down an abundant whitish, lime-like sediment. 
Causes.-The amount of phosphates in the urine is influenced by food, 
drink, age, injury, and disease. Beef, 
potatoes, and bread yield a much larger 
amount than sugars, fats, and starchy 
substances. Persons living in lime- 
stone districts, where the water is 
strongly impregnated with lime, fur- 
nish a urine richer in phosphates than 
those who reside in districts where the 
water is soft. The urine of individuals 
advanced in life contains a much larger 
amount of these materials than is found 
in that from a young person. In in- 
juries affecting the spinal marrow, as 
in fractures of the vertebrae followed 
by paralysis, the urine becomes so 
loaded with phosphates that the de- 
posit has been mistaken for an accu- 
mulation of pus or muco-pus. The 
same is true in rheumatoid arthritis, in 
chronic cystitis, and in rickets. Every- 
thing which makes large drafts on the nerve-tissue, as intense study or pro- 
tracted grief, conduces to the same result; though there are some excellent 
authorities, and among them Beale, who do not give their unqualified assent 
to this statement. The long-continued use of alkalies, by changing the normal 
acid reaction of the urine, is also regarded as a cause of phosphatic deposits. 
Accompanying this condition of the urine there are well-marked symptoms 
of disturbance both of digestion and of assimilation, as flatulency, eructation, 
abdominal distention, and emaciation, accompanied with fretfulness and 
depression of spirits. 
Carbonate of lime sediments are not common. They occur in an amorphous 
form, sometimes mingled with minute spheroidal and stellated crystals. The 
addition of nitric acid dissolves the deposit with some effervescence. 
Treatment.-Much attention must be given to correcting any irregulari- 
ties of the digestive organs w'hich may be found to exist. To this end the 
diet will require to be restricted, allowing only such articles as are found to 
produce neither gastric nor intestinal irritation. The bowels are to be regu- 
lated, if necessary, by laxatives; and, as an alkaline state of the urine is so 
prominently concerned in the production of these deposits, acids, as the 
nitric or the nitro-muriatic, should be regularly administered largely diluted. 
Tonics, as the tincture of iron and quinine, will sometimes prove of value, 
or if they are not well borne, as is not unfrequently the case, we may sub- 
stitute with great advantage the compound infusion of gentian, with the 
tincture of nux vomica and dilute phosphoric acid. 
Cod-liver oil, and the superphosphate of lime, are also valuable remedies, 
especially when the bones become affected, as in rickets. As considerable 
restlessness and general nervous excitement are always present in these 
cases of phosphatic deposits, opium becomes valuable as a means of quieting 
and disposing to rest. 
Cystine.-This unusual deposit, first recognized by Wollaston, is remark- 
able for the amount of sulphur (26 per cent.) which it contains. It is found in 
both acid and alkaline urine, and forms when deposited a sediment of a whitish 
or dull yellowish-gray appearance, which, when subjected to a microscopic 
examination, exhibits six-sided crystals of different sizes and often one super- 
imposed upon another. They bear some resemblance to crystals of uric acid, 
but are very much smaller. Should any doubt arise in the matter of dis- 
tinction, it may be promptly settled by adding a few drops of a mineral acid, 
Fig. 1367. 
Crystals of the triple phosphates. URINARY CALCULUS. 
629 
which will produce no effect on uric acid, but will quickly dissolve the crystal 
of cystine. The urine which furnishes cystine is pale, and emits a sweet- 
brier odor, which is probably due to the commingling of sulphuretted hy- 
drogen and ammonia. This substance is the principal constituent of the 
cystine calculus. 
Cystine is insoluble in carbonate of ammonia, but soluble in potash. It is 
supposed to be formed in the liver, though nothing positive is known with 
regard to its origin. It is never found in the body in health. The cystine 
diathesis which underlies the cystine calculus is one in which the symptoms 
are so subjective as to pass unnoticed, the stone attaining considerable bulk 
before being recognized, so little uneasiness does it produce. A remarkable 
feature belonging to cystine urine is its entire independence of any other 
deposit. 
Treatment.-Ignorant as we are on the subject of the origin of cystine, it 
is difficult to prescribe with any degree of confidence the treatment best 
adapted to correct the diathesis. It has been advised by Harley that in 
selecting the articles of diet all substances should be excluded which contain 
much sulphur, as eggs, peas, beans, and also protein substances, as albumen 
and fibrin, using in lieu thereof substances belonging to the saccharine, oily, 
and starchy groups. He would apply the same rule to the subject of drinks, 
which would exclude all mineral waters containing the sulphate of magnesia 
or of lime. The same objection would hold against citrates, acetates, and 
tartrates, none of which exert any solvent power on the cystine. As tonics 
among the mineral acids the nitric is to be preferred, and among the fer- 
ruginous class of remedies the tincture of the chloride of iron will be found 
to prove most efficacious. 
In addition to the use of the above remedies, the patient should not neglect 
the advantages of judicious clothing and exercise in the open air. 
Urinary Calculus. 
Urinary calculus commences either in the kidneys or in the bladder. A 
very large number of all vesical calculi begin in the former, in consequence 
of a deposit of certain saline matters from the urine, as uric acid, urate of 
ammonia, or oxalates, which gradually coalesce and form a small mass or 
concretion. This in time is passed into the pelvis of the kidney, and from 
thence transferred along the ureter to the bladder, where, if not expelled 
from the viscus, it constantly attracts to itself the salts of the urine until it 
attains a sufficient magnitude to create the usual signs of calculus. The 
triple phosphates of ammonia and magnesia are very seldom concerned in 
the formation of renal calculi. 
When stone forms primarily in the bladder, it is referable to one of the 
following causes, namely, first, a precipitation or deposition from the urine, 
induced either by abnormal alterations in the secretion itself, or by inflam- 
matory changes wrought on the mucous membrane of the bladder; and, 
second, the presence of a foreign substance introduced into the viscus either 
accidentally or designedly. 
Calculi which are composed of uric acid or of oxalate of lime have their 
origin almost always in the kidney. Those which originate in the bladder 
are generally phosphatic. 
Stone in the bladder is not confined to any period of life. It may exist 
before birth, and is met with from infancy to extreme old age. A very large 
proportion, however, of urinary calculi occur early in life. In a collection of 
8574 calculous patients,* 4986 were under twenty years, 748 between twenty 
and thirty, 438 between thirty and forty, 588 between forty and fifty, 685 
between fifty and sixty, 772 between sixty and seventy, and 338 between 
seventy and eighty. 
The collections of Civiale, Coulson, and Thompson in the aggregate amount 
* Gross on Diseases of the Urinary Organs. 630 
INJURIES AND DISEASES OF THE GEN ITO-URINARY ORGANS. 
to 10,467 cases of calculi. In Civiale's collection 55.56 per cent, of the cases 
were in patients under twenty years of age, in Coulson's collection 71.20 
per cent., and in Thompson's 60.42 per cent. Taking the three collections 
together, 62.33 per cent, were under twenty years of age. By the same 
plan of estimate, 12.96 per cent, were between twenty and forty years of 
age, 12.33 per cent, between forty and sixty, and 10.77 per cent, between 
sixty and eighty. 
In 187 cases of lithotomy performed at the Medical Missionary Society's 
Hospital, Canton, and reported by Dr. Kerr,* 65 of the patients were under 
twenty years of age, 33 between twenty and thirty, 40 between thirty and 
forty, 22 between forty and fifty, 21 between fifty and sixty, 5 between sixty 
and seventy, and 1 between seventy and eighty. These estimates, however, 
are calculated to mislead, from the disparity which must necessarily exist 
between the different classes of patients when the number of each is con- 
trasted with the entire population living at the same ages. Were the statis- 
tics based on this principle, a result the reverse of that exhibited would be 
shown. In other words, the tendency to calculous disorders would be found 
to increase with advancing age. The inaccuracy of all statistics with regard 
to the age of calculous patients will be further shown by the fact that the 
date has been fixed at the time the patient was operated on, though the 
disease may have existed several years previously. 
It would appear, however, from certain observations made by Cadge, that 
locality has some determining influence with regard to the class of patients 
attacked. Thus, most of the patients who labor under stone in the midland 
counties of England are children, while in Aberdeenshire they are adults. 
The frequency of stone in the bladder is modified by geographical con- 
ditions. In some portions of this country vesical calculi are much more 
common than in others. This is true of Kentucky, Virginia, Ohio, Missouri, 
Alabama, Maryland, Indiana, Pennsylvania, and Tennessee; while in New 
York, Georgia, North Carolina, South Carolina, Mississippi, Illinois, Arkansas, 
Wisconsin, Iowa, Texas, Louisiana, and most of the New England States 
stone in the bladder is not common. The same may be said of Mexico. In 
England stone is more common than in Scotland, and in Scotland it is more 
common than in Ireland. In Norway and in Sweden calculus is rare. 
Certain districts of a State will furnish more cases of calculus than others. 
Thus, a very large proportion of the cases of stone occurring in Pennsyl- 
vania are met with east of the Alleghany Mountains. Even in the city of 
Philadelphia the disease is more common in the former district of Ken- 
sington than in any other portion of the city. The district of Norfolk fur- 
nishes nine-tenths of all the cases of vesical calculi that occur in England. 
The northern counties of Ireland and Scotland furnish more cases of stone 
than the other portions of those countries. In Central Russia calculous 
disease is much more commonly observed than in other portions of the 
empire. It was thought by Allan Webb that India was exempt from this 
disease altogether, but it has been shown that calculus is there quite com- 
mon. A single museum contains 300 specimens of calculi removed from 
natives in different districts of the country, while 554 operations of lithotomy 
were performed in six months in the Punjaub and northwestern and central 
portions of the empire. 
Carter states that in the Presidency of Bombay, or Western India, stone is 
more common than in the Southern, or Madras Presidency. 
In China stone is confined almost exclusively to the province of Canton. 
Dr. Kerr states that missionary hospitals have been in existence for more 
than twenty years in Ning-po and Shanghai, and at Pekin and Han-kow for 
eight years, which have been attended by thousands of patients, and yet 
not a single case of stone has been met with in any of these institutions. 
The first lithotomy done in China was performed by the Rev. P. Parker, 
founder of the Medical Missionary Society. 
* New York Medical Journal, 1871, p. 365. URINARY CALCULUS. 
631 
Calculous disease is quite common both in France and in Germany, also in 
Egypt among the Arabs. 
Females are much less subject to vesical calculus than males, in con- 
sequence, no doubt, of the shortness and great dilatability of the urethra, 
by which any deposit or concretion that may reach the bladdei' is readily 
discharged. 
The liability to stone is supposed to be influenced in some degree by 
peculiarities of race. In the United States it would appear that the negro 
population enjoys a much greater immunity than the white. Of 443 cases 
of lithotomy performed in seven Southern States, only 63 were practiced on 
negroes and mulattoes,* while 380 were done on whites. The same im- 
munity on the part of the negro in Central Africa was observed by Dr. 
Livingstone. 
The formation of stone has been attributed to the geological conditions of 
the soil. Thus, it has been supposed by Harley and others to be favored by 
drinking the hard water of limestone districts; but a careful inquiry will 
show that it is quite as common in the freestone as in the limestone districts 
of those States which supply the largest number of calculi. In Pequea and 
Conestoga valleys, portions of Lancaster County, Pennsylvania, abounding 
in limestone, and where the water is very strongly impregnated with lime, 
calculi are rarely met with. Besides, it is difficult to understand how uric 
acid calculi, which constitute a large proportion of all stones, could be formed 
out of lime. 
Too free indulgence in wine has been charged with creating a disposition 
to stone. Fortified and acid wines may possibly have some effect of the 
kind, by disturbing the function of the liver, but the purer quality of clarets, 
Bordeaux and Burgundy, and the wines of the Rhine do not appear to pos- 
sess any such properties: on the contrary, there is reason to believe that an 
opposite effect is produced. If it is true, as is supposed by Liebig, that the 
bitartrate of potash, which is present in great abundance in these wines, is 
changed into the carbonate of potash while passing through the digestive 
organs, which would tend to preserve an alkaline state of the urine, such an 
effect would be explicable. At a large convention of wine-growers in France, 
the subject of rheumatic and gouty disease as a result of wine-drinking was 
made a matter of special inquiry, when it was found that the members of 
this body really enjoyed a remarkable exemption from any disorders of the 
kidneys or the bladder, and that among them were a large number of very 
aged men. No small importance has been attached to the effects of cold, 
rough weather, peculiar to districts along the sea-coasts, as predisposing to 
calculous disorders; but Mr. Cadge states that of 1500 stone cases in Norfolk, 
England, fewer came from the villages along the coast, where the cold is 
greatest, than from places inland; and in the United States, New Jersey, 
having so extensive a line of sea-exposure, furnishes very few cases of 
stone. 
Stimulants which act strongly on the kidneys have been supposed to exert 
an antilithic effect; but that they possess no properties of this nature will 
appear from the frequency with which stone occurs among the inhabitants 
of Holland, who so largely and generally use gin. 
The most probable predisposing causes for the production of calculous dis- 
orders must, I think, be referred to conditions of the nutrition resulting from 
derangements of the digestive organs, and produced by improper food or its 
defective preparation for the table, insufficient exercise, or exposure, together 
with unpropitious hygienic surroundings. The frequency with which the 
poorer classes suffer from stone would seem to favor such a supposition. I 
shall have occasion to refer to this subject again. 
Nor must we overlook the influence of family tendencies to stone. Mr. 
Cadge, in his address before the British Medical Association, refers to several 
instances in support of this. Five times has he operated on brothers for 
* Gross on Diseases of the Urinary Organs. 632 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
stone. He cites also the remarkable history of a calculous family reported 
by Mr. Hubbe, of Lowestoft. Three brothers were operated on; a fourth had 
stone; the fifth child died with symptoms of the disease; a female child was, 
at the time this record was made, suffering from vesical irritation character- 
ized by bloody urine; the father and mother passed large quantities of lithic 
acid; the grandfather had also passed a stone; the grandmother passed seven 
calculi; the great-uncle had been cut for stone; six uncles, four aunts, and 
a cousin had attacks of gravel. Montaigne and his father both died from 
stone. The two Walpoles, Robert and Horace, and also their mother, suffered 
from stone. 
Obstructions to the free escape of the urine, such as exist in stricture and 
in hypertrophy of the prostate, though calculated to oppose the passage of 
the urine, are not, in my experience, very often associated with vesical cal- 
culus. 
Chronic inflammation of the bladder and atony of its coats conduce to the 
formation of stone; deposition of the earthy salts of the urine takes place, in 
consequence of a portion of the secretion being too long retained in the 
viscus, or from the reaction of the saline matter on the mucus which is 
secreted so abundantly in cystitis. The formation of stone, when the nucleus 
begins within the kidney, is doubtless due in many instances to a purely local 
cause altogether independent of geographical, dietetic, or other general causes. 
This is evident from the frequency with which calculous concretions are met 
with in the pelvis of one kidney, while nothing of the kind exists in the 
other. 
Construction of Calculi.-In order to the formation of a calculus it is 
generally necessary that there should be some central mass, called a nucleus, 
around which the saline or organic constituents of the urine are deposited, the 
process being one chiefly of deposition and of crystallization, conjoined with 
a cementation of the particles by organic matters. Just what this organic 
matter is, and its mode of deposition, have not been definitely determined ; at 
least there is a diversity of opinion on the subject,-some, as Marcet, believing 
it to be mucus; others, as Fourcroy, albumen; and others, again, fibrin or 
gelatin. Indeed, various organic matters, as blood, mucus, epithelial scales, 
pus, etc., may become incorporated with or entangled among the cohering 
particles of the inorganic salts of the secretion. 
Number.-The number of calculi varies greatly. In most instances they 
are solitary, though there may be several. Two, three, or four are quite fre- 
quently met with. In a patient I cut for stone in Ashland, Pennsylvania, 
there were over three hundred calculi, varying in size from a grain of shot 
to a cherry. The most remarkable instance of multiple calculi is that of Chief- 
Justice John Marshall, from whom Dr. Physick extracted over one thousand, 
their sizes varying from a grain of shot to a small marble. These stones 
are preserved among the calculi in the museum of the medical department 
of the University of Pennsylvania. The mulberry calculus is almost in- 
variably solitary; generally, this is also true of stones composed of uric 
acid. The departure from this rule is met with most commonly in phosphatic 
stones. 
Size and Weight.-Most calculi are about the size of a small hulled walnut, 
and in weight four or five drachms. From this standard, however, there are 
many deviations, from a concretion the size of a grape-seed to that of an 
orange. The largest calculus removed from the bladder by lithotomy in this 
country was one extracted by Dr. Dunlap, of Springfield, weighing twenty 
ounces. Morand speaks of a stone which weighed six pounds, and one of a 
like weight is mentioned by Kesselring. Uiterhooven, of Brussels, has one 
in bis possession which measures six and a half by four and a half inches.* 
Verduc mentions one which weighed three pounds and a quarter. A patient 
died in the Philadelphia Almshouse whose bladder was almost completely 
filled by a calculus the size of a very large orange. 
* Hospital Gazette, December 13, 1879, p. 644. URINARY CALCULUS. 
633 
Mr. Earle has recorded the history of a calculus the weight of which was 
forty-four ounces. Several others of like dimensions and weight are recorded 
in works on the subject. 
There is no correspondence between the bulk of calculi and their weight. 
The latter is determined by the composition of the concretion. A cal- 
culus consisting of oxalate of lime will be much heavier than one of the same 
size the composition of which is phosphatic. A stone will weigh more im- 
mediately after its extraction than several days following, when it has become 
dry. 
The dimensions of a stone do not depend on the time that it has remained 
in the bladder. In this respect there is a great want of uniformity, chiefly 
in consequence of the constitution of the calculus. Those composed of the 
triple phosphates frequently attain a very considerable bulk. This is not the 
case with stones which are composed of uric and oxalic acids. 
Consistence.-The consistence of calculi, like their weight, depends on their 
chemical constitution. Thus, we find them in some instances soft and crum- 
bling under pressure, like a mass of coarse mortar, while in other cases they 
possess the hardness and density of marble. There are other conditions be- 
sides that of composition which tend to influence the consistence of calculi, 
such as the manner in which the particles of the mass are held together, and 
the rapidity with which the stone grows. When these particles merely cohere 
like so many grains of sand, forming a concrete by a connecting bond of 
animal or organic matter, it requires but little force to break the mass down 
compared with that necessary to crush one the components of which are 
laid down in strata. The calculi which stand highest in the scale of density 
are those consisting of oxalate of lime; next, those composed of uric acid; 
and last, those formed of the ammoniaco-magnesian phosphates and phos- 
phate of lime, or such as are constructed out of the triple phosphates. 
When the stone increases rapidly in size, it has not the same compact 
structure as when the growth goes on more tardily. 
Form.-Urinary calculi differ in shape according to their position in the 
urinary passages. When situated in the kidney, they may assume the form 
of the pelvis or infundibula, their branches being moulded into the inequal- 
ities of the different parts so as to resemble a piece of coral. When fashioned 
in the ureter, they have an oblong shape. Vesical calculi are generally round, 
unless when multiple, in which case they may be flat, faceted, pyramidal, 
semilunar, quadrangular, or wedge-shaped. 
Upon one occasion I removed three calculi from the bladder, each cunei- 
form in shape, and all very closely resembling one another. 
The hypertrophied muscular fasciculi of the bladder also make their im- 
pressions on the periphery of a calculus. The form of the stone is determined 
in some degree by that of the nucleus. For example, if it is built upon the 
end of a catheter which has broken off in the bladder, the concretion will be 
elongated and cylindrical. Some of the more unusual forms are those having 
a dumb-bell shape, or having a body with branching prongs, or presenting the 
appearance of the stopper of a glass decanter. One of the last-named shape 
I removed from the bladder of an Englishman in Philadelphia, who had been 
cut for stone several years before in Wales. The first operation had been 
followed by a fistula, in the upper part of which the stem of this stopper- 
shaped stone had formed, and so completely fitted the opening that no water 
escaped from the bladder, in consequence of which the opening on the surface 
of the perineum had healed. 
When the concretion forms in the prostatic sinuses it will probably present 
a multi-faceted appearance. A vesical calculus may have a prolongation 
extending into the prostatic urethra, or it may commence in the latter and 
grow into the bladder. 
The exterior of the calculi may be smooth, even polished, if the stone is 
hard, and there are more than one present, the friction of their surfaces pro- 
ducing this condition. 634 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
More generally the external surface is rough or granular, and in the case 
of the oxalate concretion it is tuberculated or knotty like the exterior of a 
mulberry: hence the name, mulberry calculus. 
In other eases the surface may be mammillated, or 
have projecting spikes or prongs, or it may bristle 
with spines, resembling the chestnut-bur; a specimen 
of this form of calculus is in my possession. (Fig. 
1368.) When a number of distinct spherical calculi 
become adherent, they form what might be termed 
the grape-shot figure. To these may be added the 
button, the kidney-shaped, and many other varieties. 
Color.-The color of a calculus, while it does not 
reveal the interior composition, indicates the chem- 
ical constitution of its exterior. A white or grayish 
color belongs to the soft phosphatic stones; a dark 
green characterizes the oxalate; a yellow color, the 
cystic; the yellow, pale brown, or reddish brown, the 
uric acid; and the cinnamon shade, the xanthic oxide 
calculi. 
Odor.-The calculus when recently extracted, in addition to having a 
urinous smell, emits a distinct and somewhat peculiar odor, dependent, it 
is thought, on the composition of the stone: thus, we have described the 
ammoniacal, the sulphurous, the seminal, the terebinthinate, and the aromatic 
odor. 
Arrangement of Structure.-In ordei* to exhibit the disposition of in- 
ternal structure it is necessary to make a section of the calculus. Occasionally 
when thus exposed the whole interior presents a homogeneous appearance, 
which is an indication that the chemical composition of the mass is the same 
throughout, constituting the simple calculus. Or it may be made up of differ- 
ent constituents, intermingled without any orderly arrangement, forming the 
compound calculus. Much more commonly do we find that the material from 
which the stone is formed, whether homogeneous or heterogeneous in its 
chemical constitution, is arranged in concentric lamina? of the same color or of 
different colors around a central body,-the nucleus. These laminae may pre- 
sent individually a uniformity of texture, or they may collectively exhibit 
crystalline lines radiating from the centre towards the circumference. The 
laminae, like the layers of woody fibres seen on making a transverse section 
of a tree, mark the alternating periods of activity and quiescence in growth 
or increase. 
At one time the constitution of the urine is such that its salts are rapidly 
deposited, until a considerable crust or layer is formed on the stone; at 
another period, either as a result of medication or from natural causes, the 
true balance between the saline and watery components of the secretion is 
established, during which no deposition takes place; and in this way the 
stone is built up, and the lines of definition which mark the separation of the 
different laminae are produced, in some sense as the geological strata of the 
earth are constructed. As most calculi are of a mixed character, the strata 
usually present different colors. 
Alternating calculi.-This heterogeneous structure reveals the different 
chemical states of the urine at different periods during the formation of the 
calculus. 
The composition of the nucleus varies in different cases. It usually con- 
sists of a few grains of saline matter, generally uric acid and its salts; some- 
times of oxalate of lime, aggregated togethei' and forming a single mass, 
though it may be multiple. In a few instances it has been formed from a 
small coagulum of blood, of inspissated mucus, or of mucous and epithelial 
cells together. The nucleus is not unfrequently introduced into the bladder 
from without. In a case of stone which I cut in the University Hospital, the 
concretion had formed around a raisin which had entered the bladder through 
Fig. 1368. 
Calculus covered with sharp 
spines. URINARY CALCULUS. 
635 
a recto-vesical fistula produced by a chicken-bone, which in its descent through 
the lower bowel impaled the bladder, and, after entering that viscus, was dis- 
charged through the urethra. In another case of stone which I saw, the 
patient, a soldier, bad been shot in battle, the ball entering the bladder and 
becoming the nucleus for the stone. Several examples of this nature occurred 
during the late American war. Besides the materials first enumerated, a 
great variety of articles have reached the bladder, either designedly or by 
accident, and have acted the part of nuclei, as peas, beans, pipe-stems, lead- 
pencils, tacks, straw, hair, corks, crochet-needles, bones, pins, needles; even 
foetal remains have found their way into the bladder, derived from the ovary, 
and have served as nuclei. 
In calculi which are amorphous, or without crystalline form, the lamellar 
arrangement may be faintly visible, while the constituents of the layers are 
made up of cohering particles like an aggregation of grains of sand. In 
other specimens there is no evidence of stratification, the concretion resem- 
bling a mass of dry plaster or mortar, which crumbles to pieces on the appli- 
cation of slight pressure. 
A stone may increase up to a certain size, and then remain a long time 
without further augmentation, through the constant use of antilithic reme- 
dies. Indeed, it is not improbable that when the process of deposition is sus- 
pended for a considerable period the stone may, through the action of the 
urine, lose its consistence and become measurably disintegrated. This is 
probably the explanation of the irregular gnawed appearance which some 
calculi present. 
Nucleus.-The nucleus of a calculus is generally situated in its centre, is 
round, oval, or compressed, and when laid open on making the section of a 
stone presents often the same concretive arrangement of laminae as the crust 
which incloses it, and may also possess the same diversity in chemical com- 
position. This central body, which, from its magnitude and its apparent in- 
dependence of all that is exterior to it, is usually regarded as the nucleus, 
may not have been the starting-point of the stone. A closer inspection will 
often detect a still smaller mass in the centre of the formation, which, bor- 
rowing a term from cell histology, might be designated a nucleolus, and 
which really constituted the true nucleus or the prime factor in inducing 
the subsequent deposition or crystallization. 
There may be one or more nuclei. Generally 
this body is firmly adherent to that part of the 
stone within which it is encased; though some- 
times, when blood or a considerable layer of 
mucus covered its surface at the time the per- 
ipheral deposit commenced, it may, in conse- 
quence of the drying of these organic matters, 
be found loose (Fig. 1369) or entirely detached 
from the layers which surround it. 
The nucleus does not necessarily possess 
the same chemical constitution as the stone 
which surrounds it. Thus, a uric acid calculus 
may have a nucleus of oxalate of lime, or the 
reverse may be the case. 
In rare instances the calculus may have no 
nucleus; at least none may be seen when the 
stone is sawed open, though doubtless one did 
exist at the commencement of the concretion, 
but, being of an inorganic and unstable nature, 
as blood, mucus, or lymph, it had gradually 
disappeared, leaving no trace of its pre-existence except the small cavity 
which it originally occupied. 
Chemical constitution and varieties of stone.-It is well established that the 
chemical constitution of calculus is much influenced by locality. For exam- 
Fig. 1369. 
Nucleus lying loose in an oxalate of lime 
calculus. 636 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
pie, Carter affirms* that in India 50 per cent, of all calculi consist of oxalate 
of lime. In England, in the collections of stones contained in the London 
College of Surgeons, in Guy's Hospital, and in the Norwich Hospital, the 
average percentage of oxalate of lime calculi is only 16.86. Dr. Hassall, of 
London, furnishes the composition of 1000 calculi, 372 of which consisted of 
uric acid alone, or mixed with urates or oxalates or phosphates of lime; 253 
of fusible calculi of earthy phosphates; 233 of a mixed nature, as uric acid, 
oxalate of lime, and earthy phosphates existing in the different strata; and 
142 of oxalate of lime. In Egypt about 12.5 per cent, of calculi are oxalate 
of lime. 
It would seem that the vegetarian habits of a population, together with the 
copious perspiration incident to a hot climate, which carries off much organic 
matter that otherwise would escape as urates in the urine, may be promi- 
nently concerned in the preponderating production of oxalate of lime calculi 
of India,-an explanation which Carter himself gives,-while in England and 
America the large consumption of animal or nitrogenized food may explain 
the frequency of uric acid calculi. 
Varieties.-The most common variety of stone is one composed of uric acid, 
first observed by Scheele in 1776, and constituting about one-fourth or one- 
fifth of all calculi. The color is usually brown, or brown with a shade 
of yellow or red. Occasionally it is of a whitish color, in which case there 
is an incrustation of amorphous urate of ammonia or of phosphate of lime. 
The form is oval or somewhat flattened, and the surface either smooth or 
covered with minute rounded elevations. (Fig. 1370.) When more than one 
calculus exist, their surfaces may be polished. These calculi vary in size 
from a coffee-grain to a pullet's egg. 
When a stone of this character is divided, it will either exhibit a series of 
various layers, each quite uniform in its thickness and all concentrically 
arranged about a nucleus having a similar disposition of its components 
(Fig. 1371), or will be without distinct laminae, presenting a uniform or 
amorphous appearance either of section or of fracture. 
In the first or concentric variety the interior has a crystalline appearance, 
Fig. 1370. 
Fig. 1371. 
The upper third exhibits the external appearance of auric acid 
calculus; the lower two-thirds show the inner structure. 
Section of uric acid calculus, exhibiting interior. 
the rays of fibres all converging towards the centre of the concretion. Some 
of these stones are exceedingly hard, the surface of the section resembling 
the interior of an agate, and when struck with the sound yield a remark- 
* St. George's Hospital Reports, 1871-72. URINARY CALCULUS. 
637 
ably clear, ringing sound. These calculi are soluble in carbonate of potash 
without evolving ammonia; also in caustic ammonia or potash ; they disap- 
pear in nitric acid with heat, effervescing, and leaving, when the solution is 
evaporated to dryness, a residuum of a red color, which on the addition of 
ammonia is changed to a purple hue. Water produces no solvent effect on 
this calculus. 
Urate of ammonia calculus.-This very rare stone, first recognized by Four- 
croy and Vauquelin in 1798, never attains any great size; it is usually ovoidal 
in form, is smooth or granular on the surface, and is of a slate, gray, or clay 
color. 
Urate of ammonia calculi occur about once in forty-six cases of stone. 
Thus, in an aggregate of 1043 calculi, 649 being in the museum of the Royal 
College of Surgeons, Edinburgh, and 394 in Guy's Hospital, there are 21 
composed of urate of ammonia. These stones occur chiefly in children, are 
quite compact, not brittle, and are uniform in texture in consequence of the 
urate being generally deposited as an amorphous sediment rather than con- 
centrically laminated. 
This calculus is soluble in carbonate of potash, liberating ammonia, par- 
tially soluble in cold water, soluble in boiling water. A solution in water 
with a little ammonia, when evaporated, deposits wedge-shaped crystals, and 
when heated with caustic potash emits an ammoniacal odor. 
Uric or xanthic oxide.-This substance was first discovered in a small cal- 
culus weighing only eight grains, by the elder Marcet, in 1815. Up to this 
time only four calculi of this kind have been reported. The stone is hard, 
on section presents a shining, brown appearance, and, though laminated in 
concentric layers, has no fibrous or crystalline appearance. 
The xanthic oxide calculus is soluble in ammonia and in caustic potash, 
not crystallizing when evaporated. From its alkaline solutions it is precipi- 
tated by acids. It is insoluble in carbonate of potash, soluble with the aid 
of heat and without effervescence in the mineral acids, particularly nitric. 
Its solution in hydrochloric acid on cooling furnishes minute crystals (hydro- 
chlorate of xanthin) visible only with the aid of the microscope. 
Oxalate of lime calculus is next in frequency to the uric acid, forming about 
one-seventeenth of all stones. It was discovered 
by Wollaston in 1797, is generally of a dark-brown 
color, is very rough or irregular, and is tubercu- 
lated or spinous on the surface. (Fig. 1372.) It 
is this irregularity and the rich dark-brown appear- 
ance of the exterior of the concretion which have 
acquired for it the name of mulberry calculus. It 
rarely exceeds in bulk the size of a walnut. The 
peculiar tubcrculation of the surface of this stone is 
supposed to be due to the constancy with which 
the oxalate maintains the crystalline condition 
during its deposition. In the interspaces between 
the prominences of this stone it is not uncommon 
to find deposited amorphous urates and phosphates. 
When the stone is divided, the interior presents a 
series of undulating or waving laminae with a cen- 
tral nucleus made up also of concentric layers. 
This calculus is soluble in hydrochloric acid, and on the addition of heat 
effervesces. In mineral acids it is soluble, but without effervescence; insol- 
uble in acetic acid; decomposed by sulphuric acid, giving off carbonic acid 
and carbonic oxide; and when a solution in a mineral acid is neutralized, it 
gives a white precipitate with carbonated alkalies and oxalate of ammonia. 
There are three varieties of the oxalate of lime calculus. First, the small 
round, or oval, perfectly smooth stones, which from their resemblance to 
hemp-seed have been distinguished by the name of hemp-seed calculus. They 
are rarely solitary, generally multiple. The second variety is met with in the 
Fig.1372. 
Surface of an oxalate of lime 
calculus. 638 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
condition of unmixed crystalline oxalate of lime; being almost entirely devoid 
of any cementing organic matter, it crumbles to pieces on drying or under 
pressure. The color of these concretions is pale yellow or brown. The third 
variety, first described by Mr. Charles Williams, of England, is exceedingly 
rare. The surface may be uniform, smooth, or irregular, though in the latter 
condition the eminences are free from any roughness due to the deposit of 
crystals. The chief characteristic of the concretion is its snow-white appear- 
ance, which is supposed to be due to its permanent habitat being in the 
pelvis of the kidney, where the stone is only slightly covered by the urine. 
The chemical and microscopic tests show that this stone consists entirely of 
pure oxalate of lime, being insoluble in potash and acetic acid, and displaying 
under the glass the characteristic octahedral crystals. Though all oxalate 
of lime calculi begin in the kidney, and subsequently pass into the bladder, 
in the few instances in which the present condition has been met with it has 
never been seen out of the kidney. 
Cystic oxide calculus.-Another rare form of calculus is the cystine (Fig. 
1373), only three of the kind existing among the 649 calculi contained in the 
Hunterian Museum. Ten specimens are contained 
in the collection of Guy's Hospital, all passed by a 
single patient. Many surgeons of the largest expe- 
rience have never met with a case. Civiale, whose 
great reputation in the department of stone surgery 
must have attracted a vast number of patients suf- 
fering from calculous disorders, met with only eight 
cases; and Gross says that no example of a calculus 
of this kind has occurred in his practice. This con- 
cretion was discovered by Wollaston, in 1805, and 
named cystic oxide, under the impression that it 
originated in the bladder (a supposition which 
has been found incorrect, as this calculus, like the oxalates, has its beginning 
in the kidneys). These concretions have irregularities over the surface, 
which may be either smooth or sharp. In structure there is an absence of 
orderly crystallization, the interior appearing somewhat transparent and in 
color and lustre very strongly resembling beeswax. These calculi do not 
attain any great bulk, the largest being in the University College Museum, 
London, and weighing 850 grains. The chemical peculiarity of the cystine 
calculus is the quantity of sulphur which it contains, amounting to one-quarter 
of its weight. Hereditary influences appear to be potential in the formation 
of this calculus. Mr. Poland mentions that out of a collection of 22 cases of 
cystine concretions, 10 occurred in four families, and in 3 the subjects of the 
stone-trouble were brothers. 
The cystic oxide calculus is soluble in ammonia, crystallizing, when evap- 
orated, in hexagonal plates, insoluble in carbonate of ammonia or potash, 
soluble in oxalic acid but insoluble in acetic and tartaric acids, soluble in 
both mineral acids and alkalies, but not affected by water or alcohol. 
Phosphate of lime calculus.-A pure phosphate of lime calculus, for the dis- 
covery of which, in 1797, we are indebted to Wollaston, seldom occurs, the 
phosphate being usually mingled with other saline materials. Two varieties of 
this concretion are described, the first of renal origin, possessing a pale-brown 
color, a smooth, sometimes polished surface, and an oval form, and generally 
not of large size. It is arranged in concentric layers, which adhere to one 
another with but little tenacity, and are easily broken down, on account both 
of the soft, friable nature of the material, and of the large amount of organic 
matter which it contains. This variety is composed of a neutral phosphate 
of lime. 
The second variety, more common than the first, is composed of phosphate 
of lime (bone-earth) aggregated into a granulai* mass; the particles, like dry 
mortar, are loosely bound together, and slimed over with organic matter, 
chiefly vesical mucus. This calculus is formed in the bladder. In both va- 
Fig. 1373. 
Cystine calculus. URINARY CALCULUS. 
639 
ri eties (the renal and the vesical) of phosphatic stones the concretion may 
have a nucleus of uric acid. 
These calculi dissolve without effervescence in hydrochloric acid. 
Ammoniaco-magnesian phosphate calculus.-This is a triple phosphate, and 
was discovered by Wollaston the same year (1797) in which was discovered 
that consisting of phosphate of lime. This stone has a white color; it is 
friable or soft in texture, non-laminated, exhibits no diversity of texture, but 
resembles a lump of chalk, and is covered on the surface 
with crystals. Concretions of this material frequently 
increase to a very large size. In a case occurring in the 
bladder of a female it attained the bulk of a goose-egg, 
and ulcerated its way into the vagina. 
Fig. 1374 represents a calculus of this kind belonging 
to my private collection. 
This stone dissolves in mineral acids, is not affected 
by caustic potash, dissolves in acetic acid with efferves- 
cence, and is very fusible under the flame of the blow- 
pipe, giving off an ammoniacal odor. 
The mixed phosphate, or the fusible calculus, also discovered by Wollaston in 
1797, is the most common among phosphatic calculi. It consists of three 
salts, the phosphates of lime, magnesia, and ammonia, and constitutes, it is 
believed, about one-twelfth of all calculi. The fusible calculi are chiefly due 
to an ammoniacal change in the urine, brought about by a pre-existing cys- 
titis. These formations have a white or a gray color, and vary in form. They 
are very light and friable, crumbling, when 
firmly pressed, into a powder. (Fig. 1375.) 
A section of a stone of this kind discloses 
in some specimens a concentric disposition 
of loosely-adhering lamina? with interposed 
crystals of the triple phosphates; in others 
the laminated arrangement is absent; while 
in others, again, there exists a disorderly 
accumulation of crystals mingled with the 
other portions of the concretion. 
The diversity of appearance presented by 
these calculi depends on the predominance 
of one or other of their triple constituents. 
When the triple phosphate is largest in 
amount the crystalline form will prevail, 
and when the cretaceous phosphate prevails 
the structureless appearance will be most 
noticeable. When a catheter is allowed to 
remain too long in the bladder, or when 
some foreign matter is introduced into the 
viscus from without, the incrustation which 
collects on either is composed chiefly of these triple phosphates. I have 
before me a mulberry calculus which is covered several lines in thickness 
with a snow-white deposition of these salts, particularly the phosphate of 
lime. 
A solution of the fusible calculus in acid with an excess of ammonia fur- 
nishes a white precipitate, partly crystalline and partly amorphous, and 
fusible under the blow-pipe, leaving a white glass-like substance. 
Carbonate of lime calculus, discovered in 1819 by Brugnatelli, is exceedingly 
uncommon. In all instances in which this form of stone has existed, the con- 
cretions were multiple, varying from five to forty-five in number. Stones of 
this substance are never large, rarely exceeding an almond in size. They are 
very hard, and possess both a lamellar structure and a serpentine arrangement 
of lines similar to those existing in the oxalate of lime calculus. Prostatic 
calculi have a similar structure. The carbonate of lime calculus is soluble in 
Fig. 1374. 
Ammoniaco-magnesian phos- 
phatic calculus. 
Fig. 1375. 
Mixed or fusible calculus. 640 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
hydrochloric acid, in mineral acids, and in dilute acetic acid, effervescing 
with the latter, as also after heating. Besides the calculi already named, 
other concretions have been described, as the fibrinous, the urostealith, the 
blood, and the silicious calculi, all of which lack the true characteristics of stone. 
The fibrinous concretion of Marcet and Prout is nothing more than a mass 
of albuminous or fibrinous matter, or some allied substance, in which the 
salts of the urine have become entangled, giving it a faint resemblance to 
crystallization. 
The urostealith concretion is a body bearing some resemblance to fatty 
matter, though its exact chemical constitution has not been determined. All 
that is known with reference to this substance has been communicated to the 
profession by Heller,* and by Moore,f of Dublin, whose observations were 
made on a number of these concretions passed from the bladder of a young 
man who had previously complained of vesical irritation with lumbar pain. 
The largest of the bodies passed was about the size of a hazel-nut. When 
dry, the concretions were readily broken, presenting a wax-like appearance. 
On the application of heat they melted, disengaging an odor like that of 
benzoin. Ether and caustic potash dissolve urostealith, but it is not affected 
by either alcohol or boiling water. 
Blood concretions, small dark bodies consisting of amorphous phosphates 
and blood-corpuscles mingled together and found in the pelvis or infundibula 
of the kidney, have been described by Alison. 
Symptoms.-A calculus, wherever formed, when once in the bladder, acts 
as a foreign body, and gives rise to a characteristic group of symptoms. 
Even before a concretion which may have been formed in the kidney has 
reached the bladder, there will be signs which announce that its descent is 
in progress, such as occasional attacks of nephritic colic. Many persons, 
however, carry for a long time in the bladder a calculus which may cause so 
slight inconvenience as to attract but little attention from the patient. This 
is most likely to occur when the surface of the concretion is smooth. In 
other persons, again, the symptoms of vesical irritation, at first quite urgent 
in the early history of a stone, may gradually subside. There are several 
conditions to explain this apparent anomaly, the most important being an 
increase in bulk, rendering the position of the calculus more stable; the filling 
up of surface inequalities by a new salt, thus rendering it less irritating to 
the mucous membrane of the bladder; and, last, the growing tolerance of 
the latter to the presence of the A remarkable example of this 
occurred to Morand, who sounded a patient complaining of vesical distress, 
and detected, as he believed, a stone. The symptoms shortly after abating, 
it was supposed that the surgeon was in error. The patient before his death, 
which took place from another cause, sarcastically directed that his body 
should be handed over to Morand for examination, in order that the mis- 
take might be established beyond peradventure. The post-mortem, however, 
proved that the surgeon was right, as three calculi were found, which had 
become smooth by attrition with one another. I once sounded a patient for 
stone who was suffering much from bladder irritation, and detected the con- 
cretion. Soon after the uneasiness disappeared so completely that no incon- 
venience was experienced for three years, when the vesical distress returned. 
I was again called, and removed four stones by the operation of lateral 
lithotomy. 
The symptoms indicative of vesical calculus may be arranged under two 
heads, namely, the rational and the physical. 
Bational signs.-Among the earliest of these is frequent micturition. The 
patient has frequent calls to urinate, particularly during the day, less fre- 
quently at night. He may be compelled to empty the bladder every hour 
or two hours, and in some instances every half-hour. When the desire to 
* Heller's Archives, 1844-45. 
f Dublin Quarterly Journal, May, 1814. 
j Memoires de l'Acad€mie des Sciences, 1740 (Holmes). URINARY CALCULUS. 
641 
evacuate the urine comes on, which is generally sudden, the inclination is 
irresistible and demands immediate obedience. The urgency of the symp- 
toms will be conditional on a variety of circumstances, as the roughness or 
irregularity of the surface of the stone, the activity of the patient, enlarged 
prostate, riding over rough roads, extreme acidity of the urine, cystitis, 
urethral stricture, etc. The stream of urine is also frequently subjected to 
interruption; it at first flows freely, but after a time either begins to dribble 
or stops short and cannot be resumed until some device, as a change of 
position, is adopted. This interruption is due to the calculus being car- 
ried by the current of urine into the neck of the bladder and acting as a 
stopper. The obstruction is much more likely to occur in the early period 
of stone, when the concretion is small and therefore easily swept forward by 
the water. After the calculus has acquired considerable bulk, it is less prone 
to change its position. In some cases where the stone is small it becomes 
impacted in the neck of the bladder, and requires instrumental means for its 
dislodgment. It is true that frequent micturition is not. peculiar to calculus. 
It may be produced by prostatic disease, by cystitis, urethritis, stricture of 
the urethra, emotional and other causes, and consequently of itself has only 
a limited diagnostic value. But on a careful analysis of many of the cases 
in which it is present, there will be found pre-existing or concomitant con- 
ditions which rarely lead to a false deduction. If it has been preceded by 
or accompanied with an attack of renal colic, or if the patient has passed 
gravel, the value of these symptoms is increased. 
Pain is another important and early symptom of stone in the bladder. It 
is often very severe, darting and burning in its character, and is experienced 
during micturition, but most acutely at the termination of the act, when the 
collapsed walls of the bladder grasp the calculus. It is felt almost always 
near to or a short distance behind the external urinary meatus, and will often 
continue until enough urine collects in the bladder to distend its walls suffi- 
ciently to remove them from contact with the stone. To relieve the suffering 
from, this source, the patient acquires the habit of constantly pressing and 
pulling the head of the penis with the fingers, which in time has the effect 
of increasing the size of the organ and elongating the prepuce. Both mictu- 
rition and pain are influenced by alterations in the constitution of the urine; 
calculi are generally made up of strata having a different chemical composi- 
tion, and, as some are less irritating to the bladder than others (for example, 
a rough oxalate of lime concretion, as a rule, occasions much greater suffering 
than a smooth uric acid or a phosphatic calculus), we have an explanation of 
those singular cases in which a patient suffers for a few weeks or months 
with active symptoms of stone and then enjoys even a longer period of com- 
parative freedom from vesical uneasiness. Another and very common cause 
of these exacerbations of pain and micturition is active exercise, as riding 
over rough roads, by which the foreign body is rolled about in the bladder. 
Fecal accumulations in the rectum, exposure to cold and dampness, ulcera- 
tion or abrasion of the mucous coat of the bladder, gouty or rheumatic 
states of the system, the use of alcoholic drinks, and peculiarities of temper- 
ament are all conditions which excite periodical aggravations of suffering. 
A stone may become fixed to a particular spot in the bladder, either by an 
inflammatory adhesion or by lodging in a pouch or diverticulum of the viscus; 
or it may become heavily coated with organic matter; and thus in the first 
case through fixation, and in the last through the filling up of all those in- 
equalities on the surface of the concretion which tend to irritate the mucous 
membrane, the patient may experience comparatively little inconvenience. 
Lastly, where calculi occur in a paralyzed or atonic bladder, both pain 
and micturition are subordinate symptoms, as little or no voluntary expulsive 
power remains in the walls of the bladder. 
Pain is often felt in cases of stone in parts both contiguous to and remote 
from the bladder,-a fact which has its explanation in the nervous communi- 
cations which bind together different parts of the body. Thus, in addition 
VOL. II.--41 642 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
to the distress at the end of the penis, a patient may complain of severe 
neuralgic pains in the rectum, down the thighs, in the back, over the hip, 
along the side of the body, and even in different parts of the arm. 
Though pain is experienced in cystitis and in disease of the prostate body, 
there is a significant distinction between that resulting from those affections 
and that resulting from stone. In the former it is always experienced just 
before, and not after, urination. 
Changes in the Appearance of the Urine.-These consist in the presence 
of muco-pus, or of blood, in the secretion. Though it is possible for stone 
to exist for some time without a trace of either of these products, in the 
large majority of instances one or the other or both may be detected. If 
muco-pus, it is the effect of cystitis, and settles to the bottom of the vessel 
containing the urine. Blood, wflien observed, can generally be referred to 
some cause which rolls the calculus about in the bladder and produces a 
lesion of some of the capillary vessels of the mucous membrane. It may 
also follow a vigorous contraction of the walls of the bladder upon the cal- 
culus. This symptom is much less common in childhood than in mature or 
advanced life. The blood rarely exceeds a few drops, which are discharged 
with the last portion of urine. When more abundant, it will impart a 
mahogany or smoky appearance to the secretion. 
Tenesmus, both vesical and rectal, is another sign attending calculus of the 
bladder. 
It is quite common in children, less frequent in adults. The patient during 
and after urination experiences an irresistible desire to strain, with a fullness 
in the hypogastrium and bearing down in the rectum. This is often followed 
by prolapse of the mucous membrane of the rectum in children, and by hem- 
orrhoids in the adult. 
Priapism is a frequent attendant on stone, particularly in children, and is 
excited by irritation reflected from the bladder to the cord. Urinary incon- 
tinence is sometimes observed both in children and in adults laboring under 
calculus. 
Physical signs.-A patient with a group of symptoms similar to those that 
have been detailed, or if only the symptoms of frequent micturition and pain 
at the end of the penis are present, should be examined by a steel instrument 
called a sound; whence the term " sounding" given to the procedure. 
Sounding.-Sounds are instruments resembling somewhat in shape the 
ordinary catheter. They are made, very unnecessarily, of several different 
curves, some of which, from their length, are utterly useless. They should con- 
sist of solid steel, nickel-plated, and should be about twelve inches in length, 
with a handle perfectly smooth, and the vesical extremity with either a slight 
or a short, abrupt curve, in order that the point can be carried into the depres- 
sion behind the prostate, or into any other part of the bladder. (Fig. 1376.) 
Fig. 1376. 
The two curves necessary for sounds. 
Two sizes only are required; the one suited to the adult, No. 13, and the 
other adapted for the urethra of a child, No. 9 or No. 10, on a scale 30. 
Sounds are sometimes traversed by a small canal, through which fluid may 
be injected into the bladder. Mr. Napier has recommended pewter oxidized 
by nitric acid as a suitable metal for sounds; the object being to furnish a URINARY CALCULUS. 
643 
surface which cannot be easily scratched by being brought into contact with 
a hard substance like stone. 
The principle of the telephone has also been applied to the operation of 
sounding. I can conceive, however, of no material or mechanical contrivance 
better adapted to the object in view than the solid steel sound constructed 
after the plan already described. The directions preparatory to sounding 
usually laid down with some minuteness by authors, with regard to cleaning 
out the bowels by cathartics or an enema, and injecting into the bladder a 
certain amount of water, provided the urine has not been retained, are seldom 
carried out strictly in practice. Nor, indeed, is it necessary that they should 
be, except in cases where, notwithstanding the existence of symptoms of 
stone, some difficulty has been experienced in discovering the concretion. In 
these cases all these preliminary measures are not only proper, but neces 
sary. Under such circumstances I prefer to make the exploration with the 
bladder very slightly distended, as the instrument has a smaller field to 
traverse. In children, in consequence of the fear, struggles, and cries which 
the act of sounding excites, the operation should be done only while the 
little patient is under the effects of ether. 
During the examination the patient should be placed upon the back, near 
the edge of the bed or the table, with the shoulders raised, the knees some- 
what drawn up, and the limbs separated, thus relaxing the abdominal mus- 
cles. The surgeon, standing on the left side if right-handed, or on cither 
side if ambidextrous, now warms the sound at least to the temperature of 
the body, oils it, and, after inserting the point into the urethra, conducts 
the instrument gently onward into the bladder, in the same manner as in 
introducing the catheter. 
Very frequently the stone is felt as soon as the sound enters the bladder, 
but if not, then the instrument is to be moved forward and backward, to the 
right and to the left; and if still unsuccessful in the search, it should be 
rotated on its axis, turning the point of the sound towards the bas-fond. 
When the stone is struck, not only will the contact of the instrument with 
the surface of the concretion be felt by the hand, but by repeated taps a dis- 
tinct clink or metallic sound will be heard, and this can be rendered still more 
audible, so as to be heard over a large room, by screwing to the handle of 
the sound the sounding-board of L'Estrange. (Fig- 1377.) 
Fig. 1377. 
Sound, with sounding-board attached. 
Too much importance cannot be attached to the testimony furnished by 
the ear: it is far more reliable than the sensation communicated to the. 
touch. 
If all the circumstances attending those errors of diagnosis, in consequence 
of which patients have been cut without a stone being found in the bladder, 
could be learned, I have no doubt it would be found that the operator pro- 
ceeded more on what was felt than on what was heard. The clearness, dis- 
tinctness, or pitch of the sound elicited on striking a calculus will depend on 
the physical and chemical character of the concretion, and also upon its 
magnitude: a hard, compact calculus composed of uric acid or oxalate of 644 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
lime will yield a more positive ring than one consisting of softer material, 
like the phosphates, and a stone the size of a -walnut will give out a clearer 
ring than one the dimensions of which do not exceed those of a grain of 
coffee. All the manipulations attending the use of the sound must be con- 
ducted with the utmost gentleness and care. Otherwise serious injury may 
be sustained by the bladder, causing peritonitis, acute cystitis, or even death, 
instances of which are recorded by Civiale, Sanson, and others. 
Sources of fallacy arise sometimes from a fasciculated condition of the 
bladder, in which, as the point of the instrument is swept over these ridges, 
there is imparted a sensation which counterfeits in some degree that caused 
by a stone. But let it be remembered that in such a state of the organ the 
ear never detects any sound. A more embarrassing state is that in which the 
interior of the bladder is incrusted with the salts of the urine, in which case 
it is possible not only to fee] but likewise to hear the contact between the 
instrument and the deposit. This condition, however, produces a grating 
sound rather than a click, and offers a more extended surface to the instru- 
ment than would be furnished by a calculus. A surgeon may also be led 
astray by causes which are entirely extra-vesical, as an unusual salience of 
the promontory of the sacrum, bony growths developed from the bones of 
the pelvis and encroaching on the walls of the bladder, induration of the 
prostate body, and fecal impaction of the rectum. In one instance the head 
of the femur protruding into the bladder was mistaken for vesical calculus. 
Error may also arise from the presence of a vesical growth, the surface of 
which becomes coated with a deposition of phosphates. In the case of a 
female who presented all the rational symptoms of stone, the existence of 
which was verified, as I supposed, by the sound, I found, on making a digital 
exploration of the bladder, that the patient was laboring under a papilloma 
which had become encapsulated by a saline deposit. Even in cases of this 
kind, however, there is an absence of the true calculus ring, with a greater 
sensation of roughness than belongs to stone. 
There are several sources of difficulty in detecting a calculus. 
First. The depth of the post-prostate pouch of the bladder (Fig. 1378) may 
Fig. 1378. 
Fig. 1379. 
Sounding for stone in the post-prostate pouch of the bladder. 
Sacculated stone. 
render it impossible to carry the sound to its bottom. The remedy consists 
in introducing a finger into the rectum, and raising this part of the viscus, 
so as to meet the reversed extremity of the sound; or the stone may be dis- 
lodged from its bed by placing the patient on his elbows and knees, with the 
pelvis well elevated. 
Second. The stone may be imprisoned in a side pouch or sac of the bladder 
(Fig. 1379), or may be encysted, and thus elude detection. 
When this is suspected, the organ should be distended with a fluid, and its 
■walls explored in detail by straight as well as by curved sounds. I had an URINARY CALCULUS. 
645 
opportunity of verifying the existence of a very peculiar variety of encysted 
calculus in a man over seventy-five years of age, on whom I performed lithot- 
omy. The dull, negative sensation imparted to the hand on sounding was 
satisfactorily explained on opening the neck of the bladder, when the stone, 
fully the size of a walnut, was found immovably fixed to the mucous mem- 
brane, from which I failed to dislodge it on the application of the forceps. 
On withdrawing the latter and introducing my finger into the bladder, in 
order to ascertain the source of the difficulty, I was surprised to find the 
calculus completely invested with a membrane. 
Drs. Hunt and Hunter, who were present at the operation, had an oppor- 
tunity of confirming the existence of this membrane by the touch; and it 
was only after lacerating it and shelling it off that I succeeded in removing 
the calculus. 
Third. There may be congenital malformations in which the bladder is 
divided into one or more compartments, and where a calculus might defy 
detection. 
Fourth. The stone may be caught in a fold of the bladder, owing to some 
eccentric behavior of a certain group of muscular fibres, so as to conceal its 
location. Varying the position of the patient, distending the viscus with 
tepid water, and repeated soundings, offer the most reasonable prospects of 
success in detecting the presence of a concretion thus held. 
Fifth. The bladder may be so fasciculated and the calculus so small that 
the latter may become caught in one of the intermediate depressions on the 
surface of the organ, and thus be overlooked. 
Sixth. A calculus may be suspended by a thread of lymph from the 
summit of the bladder, as in Morton's case, and thus escape detection. 
Seventh. There may be a partial anteversion of the bladder, and the stone 
be lodged against the anterior wall of the latter, behind the pubes. To touch 
a calculus so situated would require the handle of the sound to be strongly 
depressed between the thighs of the patient, with the concavity of the curve 
upward, in order that the point of the instrument should be directed to the 
proper place. (Fig. 1380.) 
Eighth. Indifference on the part of 
the surgeon to the sensations of the 
patient may give rise to error. A 
most instructive instance of this kind 
came under my observation a few 
years ago. A patient from Western 
Pennsylvania visited Philadelphia, 
in order to be relieved of a vesical 
calculus. Several surgeons w'ho ex- 
amined the man had failed to touch the 
concretion, though he himself affirmed 
that he had frequently felt it while 
using the catheter to relieve the blad- 
der, and that he could tell with entire 
certainty when the stone was tangible 
by certain sensations which he expe- 
rienced, and which he described as those of a body "rising up" in the viscus. 
On his arrival in the city he was examined by a surgeon, who decided that the 
bladder contained no calculus. When the patient applied to me, I listened 
attentively to his story about the rising up of the stone, and his inability to 
convince those who had unsuccessfully explored the bladder that it was im- 
possible to feel the foreign body at any other time. While be was describing 
the peculiarities of the case, he suddenly cried out, " The stone is rising!" I 
immediately introduced a sound, and detected two calculi, which were after- 
wards removed. 
The bladder appears to have the power in some rare instances of changing 
its form, so as at one time to conceal calculi from the most painstaking 
Fig. 1380. 
Stone lodged against the anterior wall of the bladder. 646 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
search, and at another to eject them from their hiding-place, so that they 
can be touched even by an unskillful hand. Repeated explorations alone can 
overcome this difficulty. 
Ninth. Hemorrhage in the bladder may frustrate the efforts of the sur- 
geon to detect a stone, as the coagulated blood adherent to its surface so 
neutralizes sensations resulting from the contact of the sound with the con- 
cretion that no definite opinion can be formed. 
Tenth. Calculi may dilate the ureter into a great pouch immediately behind 
the bladder, and give rise to the same symptoms as those of vesical calculus, 
yet it would be impossible to touch them with the sound. In two instances 
1 have seen crowded together in a dilated ureter a large accumulation of 
stones, which, until revealed by an autopsy, were only suspected to exist. 
Eleventh. The calculus may be buried in the prostate body, or the latter 
may be dilated by disease into a large sac, in which a stone may be hidden 
away out of reach of the sound. Or the urethra itself, near the bladder, 
may become converted into a pouch, through which the point of the sound 
may be freely swept, thus leading the operator to suppose that he is in the 
bladder when he is not. 
Twelfth. A stone may occasion so little inconvenience that its existence 
will not be suspected. Cases are on record, as those of Van Helmont, 
Deschamps, Johnson, of Richmond, and others, in which the calculus has 
attained extraordinary dimensions without giving rise to any symptoms, 
until by some unusual jar or jolting the concretion became disturbed, after 
which the usual signs made their appearance. In three cases I have seen 
calculi removed from the bladder after death, one of w'hich was the size of an 
orange, where, so far as I could ascertain, their presence had not been sus- 
pected. The passive behavior of these foreign bodies is probably to be 
accounted for by the smooth character of their exterior, and by their re- 
maining fixed in one locality. 
Exploration of the Bladder for Stone in Females is best effected by 
a straight sound: in order to avoid all sources of error from uterine disease, 
or from vesical growths incrusted with the salts of the urine, pressure should 
be made on the bladder at the same time through the vagina and above the 
pubes, or, should there remain any obscurity after the use of this means, the 
bladder should be subjected to a digital exploration, the patient having been 
previously placed under an anaesthetic. 
Not only do we ascertain the existence of stone in the bladder by sounding, 
but it is possible also to learn something about the size and consistence of 
the concretion, and also the tolerance of the organ for the use of instruments. 
The high-pitched click which follows the tap of the sound against a calculus 
signifies a hard stone, perhaps one of uric acid or oxalate of lime, and by 
carefully passing the front of the instrument over the concretion in different 
directions a rough estimate may be formed of its bulk. 
Measuring calculi.-It is desirable to have a knowledge not only of the 
probable composition of the stone, but also of its dimensions, as the method 
of dealing with the foreign body will be largely determined by the possession 
of such information. 
By introducing a lithotrite into the bladder and catching the stone between 
its jaws the diameter of the concretion may be ascertained, and not only 
so, but an examination of the fragments which cling to the blades on their 
withdrawal will furnish some clue to its composition. 
Sir Henry Thompson has very ingeniously substituted for the lithotrite in 
measuring a calculus an ordinary sound with a ring or collar, which can be 
made to slide along the shaft. (Fig. 1381.) In the application of the instru- 
ment, the latter is inserted into the bladder, and its end passed over the sur- 
face of the stone by a succession of taps, until the extreme limits of the body 
have been traversed. The collar is then to be slid down the shaft of the in- 
strument until it touches the meatus, when the sound must be drawn back 
over the calculus, tapping the latter until its surface has been passed over: URINARY CALCULUS. 
647 
the distance between the penis and the collar expresses the diameter of the 
concretion. The test, unless made with a delicate hand, must, however, be 
accepted with some distrust. 
Notwithstanding the accurate information conveyed by the sound, it some- 
Fig.1381. 
Thompson's sound for measuring a calculus in the bladder. 
times leads the surgeon astray, or at least the sensations which it communi- 
cates may be wrongly interpreted. In this way even the most distinguished 
and experienced lithotomists have been led to subject patients to operations 
for stone where none existed in the bladder. Three times Cheselden was 
deceived by his sound, and cut without finding any calculus in the bladder. 
Dupuytren, Roux, Tyrrel, and others have committed similar mistakes. 
Three times have I known the operation of lithotomy performed without 
any stone being found. 
The constitutional symptoms of stone are subject to considerable variation. 
Persons in middle and advanced life suffer more than children. Indeed, 
the latter may carry stones for years without exhibiting any material loss of 
health. In calculous patients of riper years there is a tendency to chronic 
cystitis, and also to disease of the kidneys; the constant calls to urinate, the 
loss of sleep, and the deteriorated state of the blood, which the renal organs 
in their crippled condition are unable to depurate, soon begin to undermine 
the health. The digestive organs become deranged, the patient loses flesh 
and strength, and finally, if the disease is allowed to progress without in- 
terruption, he perishes, after enduring years of suffering, worn out with 
hectic, or perhaps suddenly in a convulsion. 
Pathological Changes.-The alterations of structure which frequently 
follow the presence of stone are often very extensive and wide-spread, and 
depend on the propagation of local irritation from the mechanical effects of 
the calculus. They begin in the bladder as a cystitis, and present the usual 
characteristics of chronic inflammation of that organ, viz., increased vas- 
cularity of the mucous coat, submucous infiltration, and thickening, finally 
amounting to hypertrophy of the other tunics of the viscus, and occasionally 
ulceration of the mucous membrane. 
Twice have I known in females the ulceration to extend through the walls 
of the bladder and the stone escape into the vagina. It is more serious when, 
in the male, it enters the recto-vesical space, where it may occasion death 
from urinary infiltration. The inflammation is propagated to the ureters, in 
consequence of which they undergo thickening, contraction, sometimes dila- 
tation, and occasionally ulceration. 
The kidneys also participate in the evil, becoming inflamed, and exhibiting 
in a few instances the usual appearances of Bright's disease, or more com- 
monly undergoing suppuration, during which they become filled with ab- 
scesses, and perhaps are finally converted into a large sac containing numerous 
calculous concretions. The inflammatory changes may also extend to the 
vesiculae seminales and the seminal ducts, the walls of which, like the ureters, 
are liable to become dilated or thickened, and contracted. The vesical irri- 
tation sometimes extends to the cellular tissue of the perineum, or may result 
either in a fistula or in abscess: I have witnessed both of these conditions 
in the last twelve months. The urethra is less disposed to become involved 
than the urinary tract higher up, the morbid changes being confined chiefly 
to the prostatic portion, and consisting for the most part in an undue vas- 
cularity and thickening, which contribute in no small degree to increase the 
sufferings of the patient by provoking increasingly frequent micturition. 648 
INJURIES AND DISEASES OF THE GENITO-URINARF ORGANS. 
The prostate body rarely escapes unharmed, becoming enlarged, and offering 
considerable obstruction to the escape of urine. Changes may also take 
place in its structure. 
The plexus of veins at the neck of the bladder exhibits considerable dila- 
tation, becoming contorted and varicose, and often gives rise to troublesome 
bleeding after lithotomy. 
A calculus in the bladder has presented an obstacle sufficiently great to 
defeat parturition. An interesting case of this kind, recorded in the "New 
York Journal of Medicine and Surgery" for September, 1850, and reported 
by Dr. Monad,* demanded the removal of the stone before the labor could 
be completed. A similar case was seen by Mr. Threlfall,f one of the surgeon 
accoucheurs to the Liverpool Ladies' Charity, in -which a calculus weighing 
six ounces was mistaken for a scirrhus of the right ovary. The patient 
perished from exhaustion without being delivered. 
Spontaneous rupture of calculi has been known to happen, produced, no 
doubt, by their being rudely driven together when multiple; also by the 
explosive action of gas generated within the concretion; possibly also by the 
spasmodic contraction of the bladder around the stone. An accident of this 
kind is possible only with a soft concretion, and is one of great danger: as 
the sharp angles of the fragments frequently wound the walls of the organ, 
and excite acute cystitis, ulceration and perforation of the bladder, urinary 
infiltration, peritonitis, and death. 
The treatment of stone in the bladder is embraced under two heads, namely, 
general or constitutional, and local. 
The constitutional treatment aims at palliation, not cure, and consists in 
prescribing a regimen which will tend to correct all errors of digestion, and 
those remedial agents which through the urine are capable of exerting some 
influence on the stone. The patient must use only those articles of food 
which experience has shown to be most easily digested. It is almost im- 
possible to designate the exact articles proper in every case. What will suit 
the stomach of one person may not agree with that of another; but generally 
broiled or roasted meats, eggs, rice, white potatoes, stale bread and biscuit, 
buttermilk, oatmeal, hominy, and milk constitute the best pabulum; while 
salt meats, fried or stewed meats, fats, gravies, dressings, sugars, sweet 
potatoes, onions, warm bread, pastry, sour fruits, sweet cakes, or highly- 
seasoned food of any kind, together with wines or other alcoholic drinks, 
will be productive of harm. In persons addicted to the use of stimulants, 
and who seem to suffer from their withdrawal, the least objectionable of 
the class allowable are sound cider and Holland gin. Drinking-water which 
may be impregnated with lime should be proscribed, as its use will furnish 
the materials which go to increase the calculous disorder; and in the event 
of the patient being so circumstanced that only hard water can be obtained, 
before being used it should be subjected to boiling, by which the contained 
salts can be largely removed. The relation which the skin and the respira- 
tory organs sustain to the kidneys in the work of eliminating the products 
of oxidation renders it important to secure the healthy operation of both ; 
and to this end the body must be warmly clothed and defended against cold 
and moisture, and gentle exercise taken in the open air during pleasant 
weather, though all rough and jolting movements are to be avoided. Absti- 
nence from sexual indulgence should also be observed, as an aggravation df 
all the vesical symptoms is liable to follow any violation of this rule. 
The medicinal agents which can be given with the greatest benefit are 
those which have the effect of preserving the urine in its normal neutral 
state. The free use of water alone, by furnishing a solvent, performs a valu- 
able office in preventing urinary deposits. The patient can add much to his 
Treatment of Vesical Calculus. 
* London Medical and Surgical Journal, vol. ii., 1829. 
t Ibid. TREATMENT OF VESICAL CALCVLVS. 
649 
own comfort if properly instructed by his medical attendant. Whenever 
the urine yields an acid reaction to test-paper, alkalies are indicated; and 
when it becomes alkaline, acids are required. The alkali which in my own 
experience lias given the greatest satisfaction is the bicarbonate of potash. 
Thirty grains of the salt dissolved in a pint and a half of water should 
be taken by installments in the course of every day. The liquor potass®, 
provided the stomach is not disordered, may sometimes be substituted for a 
short time. The various nostrums which have been in use at different times 
for the cure of calculous disorders consist chiefly of alkaline substances. 
Thus, the famous antilithiC of Mrs. Stevens, purchased in 1739 by the Eng- 
lish government for five thousand pounds, at the suggestion of a committee 
appointed by Parliament, consisted of castile soap and calcined egg-shells; 
that of Lee is probably nothing more than the bicarbonate of soda with 
castile soap and the oil of juniper. I am sure the health is often seriously 
damaged by the prolonged use of these remedies. They should not be 
employed continuously for a longer period than eight or nine days. 
When the calculus is composed of the oxalate of lime or is of a phosphatic 
nature, alkalies are contra-indicated, the mineral acids being preferable, par- 
ticularly the nitro-muriatic, in doses of four or five drops largely diluted three 
or four times a day. In the use of alkalies some caution is necessary. 
Certain waters, notably the Vichy, enjoy a considerable reputation in cases 
of stone; and it is no doubt true that in view of their alkaline constituents 
they may be used with some relief. I think it probable, however, that the 
quantity of the water has more to do with the benefit derived than its com- 
position. 
When the health is broken by the long-continued irritation resulting from 
the presence of vesical calculus, preparations of iron and quinine will be de- 
manded. Opium suppositories also, during exacerbations or fits of calculous 
disorders when more than ordinary distress is experienced, will exert a 
salutary effect in quieting irritation and procuring sleep. 
Local solvents.-Although the theory of dissolving a stone by the direct 
application of certain reagents passed into the bladder is a very attractive 
and plausible one, its practical application has not met with the success 
which was anticipated. The concretions which have been most influenced 
by the local use of solvents are those of phosphatic origin, and it was in cases 
of this nature that Sir Benjamin Brodie and Mr. Southam each succeeded 
in effecting a cure. The agent employed was nitric acid (two and a half 
minims to one ounce of distilled water); the liquid was passed over the con- 
cretions by means of a double catheter for about twenty or thirty minutes. 
The acetate of lead has been used for the same purpose and in the same 
manner by Dr. Hoskins (one grain of the salt to one ounce of water). The 
new combinations which follow from the interchange of constituents, namely, 
the phosphate of lead and an acetate of lime and magnesia, do not cause 
any vesical irritation, and as the former is precipitated in the form of a fine 
sediment, it may be washed out of the bladder during urination. 
The solvents, of course, must vary with the character of the stone. For 
uric acid calculi, alkaline solutions are required, as the liquor potass® greatly 
diluted ; for oxalate of lime concretions, and for those composed of the triple 
phosphates, dilute acids constitute the proper solvents: for the first, nitric 
acid; for the second, hydrochloric acid. To produce any decided change, 
however, in a calculus, especially one having an oxalate of lime or a uric acid 
composition, these substances would require to be employed of a strength 
which could not fail to produce a corresponding effect on the mucous coat of 
the bladder, and hence they are altogether improper to be used, so that the 
question of solvents for the cure of stone in the bladder has very little to 
recommend it to the attention of the profession. The same may be said of 
the electrolytic mode of disposing of urinary calculi recommended by Bou- 
vier, Gruithuisen, Bonnet, O'Shaughnessy, and others, and put into practice 
by Dr. Bence Jones and Dr. L. Melicher. A grooved battery with twenty 650 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
pairs of plates was employed for the purpose in the experiment of Jones, 
who used a solution of the nitrate of potash, from the decomposition of 
which was obtained the nitric acid liberated at the positive pole of the bat- 
tery ; this was to decompose the uric acid of the stone, while the potash 
liberated at the other pole was to cause its solution. What may be the 
ultimate results obtained in this department of electrolytic surgery it is 
impossible to say, but at present its claims to professional confidence are 
very slight indeed. 
Extraction of Calculi. 
There are three ways in which a calculus may be removed from the 
bladder: first, by its spontaneous discharge through the urethra; second, by 
extraction with forceps by the operation of lithotrity, in which the stone is 
ground to pieces, and is either allowed to escape with the urine or is washed 
out by suction; third, by lithotomy, in which an incision is made through 
certain portions of the body offering a convenient route to the bladder. 
First. The spontaneous expulsion of stone is a common event, but when 
it occurs the concretion is usually quite small, at least in one of its diameters. 
Cylindrical calculi even one inch in length sometimes escape from the blad- 
der in this manner. 
After attacks of renal colic, systematic efforts should always be made to 
favor the passage of the concretion should it have entered the bladder, for if 
allowed to remain it soon becomes the nucleus for a stone. Should the gravel 
not be discharged in a few days after the paroxysm, its escape will be pro- 
moted by dilating the urethra to its fullest capacity with graduated bougies. 
After this has been done, the patient should be requested to retain his urine 
until the bladder becomes well distended, when it should be emptied with 
vigorous energy while he is on his hands and knees. In this posture some 
advantage is gained from the force of gravity pitching the stone forward into 
the neck of the bladder. Another plan may be adopted, should the last fail, 
namely, that of grasping the glans penis and by forcibly closing the external 
urinary meatus preventing the escape of the urine until the canal is well 
dilated by the column of water, when the pressure should be suddenly re- 
moved, at the same time the strongest voluntary efforts being made to 
empty the bladder. In this manner, the concretion is swept onward by the 
stream of urine, and, meeting with little resistance from the walls of the 
dilated urethra in front, may be expelled safely from the body. 
Fig. 1382. 
Instrumental extraction.-Two instruments have been devised for extracting 
calculi entire from the bladder of the male,-the one a large catheter with an 
Catheter for removing calculi. 
Fig. 1383. 
Forceps of Sir Astley Cooper for seizing vesical calculi. 
ample eye at the vesical extremity (Fig. 1382), and the other a peculiarly- 
shaped forceps. (Fig. 1383.) This method appears to be an old one, having LITHOTRITY. 
651 
been quite familiar to the Egyptians, as we learn from the French surgeons 
who witnessed the operation during the Eastern campaigns of Napoleon 
Bonaparte. We learn also from Prosper Alpinus that among the Egyptians 
small calculi were removed from the bladder by first inflating the urethra with 
air, and afterwards with a finger in the rectum pressing the stone into the 
neck of the bladder, from which it was drawn forward by stripping the penis. 
In using the catheter the bladder is to be well distended with tepid water, 
after which the tube is introduced, when the sudden gush of water through 
its canal will probably carry the calculus into the eyes of the instrument. 
Mr. Bell, of Edinburgh, succeeded in this way in removing from the bladder 
of a patient one hundred and fifty small stones. 
When the forceps of Cooper are employed, they are to be introduced, after 
dilatation of the urethra, into the bladder with the blades closed, and used 
as a sound or searcher. On touching the concretion the blades are to be 
separated, and by a dexterous movement made to embrace the stone, when, 
if not too large,-which may be determined by the index near the handle, 
-the surgeon may proceed cautiously to extract the foreign body. In this 
way Sir Astley Cooper, Brodie, and others succeeded in extracting calculous 
concretions. In France as early as 1561 a canula inclosing four blades was 
used for the same object. Hildanus modified this instrument by omitting 
one of the blades. 
These forceps are admirably adapted for the extraction of calculi from the 
female bladder, as will be seen farther on. 
Lithotrity. 
It is not a matter of surprise that surgeons, in view of the formidable 
character of lithotomy, the exceptional skill required for its proper execu- 
tion, and the mortality which has attended its performance, should have 
given much thought to the subject of discovering some other and less fatal 
mode of removing calculi from the bladder. The first steps in this direction 
appear to have been taken by two Italians, Santorio and Ciucci,-the former 
in 1626, and the latter in 1670. In 1814, Gruithuisen, a surgeon of Munich, 
Bavaria, brought to the notice of the profession a mode of dealing with vesi- 
cal calculi by drilling or boring, and, after having in this way honey-combed 
the stone, crushing the pieces asunder. Of a similar nature was the opera- 
tion of Elderton, of Scotland. 
While the early labors of these men are entitled to much consideration 
as giving direction to surgical thought, it is to Civiale more than to any 
other individual that we are indebted for lithotrity. This French surgeon 
as early as 1817, when a medical student, was industriously occupied devising 
instruments to render the operation practicable. The first mechanism which 
he produced, commonly known as the trilabe, consisted of a central drill and 
three arms or branches with incurved extremities. The instrument was in- 
troduced into the bladder closed, after which the branches were expanded 
and made by a gentle manipulation to grasp the stone, when the latter was 
bored through in different places and then broken. With this lithotrite 
Civiale in 1824, before a committee appointed by the Academy of Medi- 
cine, operated on two patients with stone, with much success. The subject 
was also prosecuted by Amussat in 1822, and by Leroy d'Etiolles one year 
later. The instrument of Civiale, however, was clumsy, and not well adapted 
for accomplishing the object in view. In 1824, Mr. Weiss, of London, de- 
signed a lithotrite in which the blades, two in number, were placed at an 
angle with the shaft, so that the calculus could be seized and crushed between 
them by a screw acting on the movable blade. The invention of this in- 
strument marked a very important period in the history of lithotrity, as 
it substituted crushing for boring or drilling. With a lithotrite in most par- 
ticulars like the one of Weiss, in 1825 Mr. Hodgson first performed at the 
Birmingham Hospital the operation of crushing. 652 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
The manner of communicating the force to the stone after it has been 
grasped has also engaged the attention of surgeons. In 1832, Baron Heur- 
teloup adopted the plan of fixing the handle of the instrument between the 
jaws of a vise conveniently placed by the bed of the patient, and by re- 
peated blows with a hammer on the movable blade causing the stone to give 
way. He was followed by Costello, who communicated the power to the 
jaws of the lithotrite by a modification of the screw. Changes in the instru- 
ment were subsequently made by Mr. L'Estrange, of Dublin. It was in the 
use of these last improvements that Sir Benjamin Brodie acquired his repu- 
tation in this branch of operative surgery. 
Sir William Fergusson applied the crushing power by means of the rack 
and pinion (Fig. 1384), a modification of the lithotrite, which I believe he 
never abandoned. Another alteration was made by Mr. Oldham in the form 
of the female blade, which consisted in making it fenestrated. 
The instrument was finally brought approximately to perfection by the 
conjoined labors of Civiale and the eminent surgical cutler of Paris, M. Char- 
riere. (Fig. 1385.) This lithotrite consists of a male and a female blade, 
Fig. 1385. 
Civiale and Charriere's lithotrite. 
the former moved up and down without the action of a screw, simply by 
the hand grasping the pinion or wheel placed at the end of the handle, and 
this sliding movement can instantly be changed to the screw-motion by 
slipping into place a button on the side of the instrument. The female 
blade is concave, but not fenestrated, and its edges are beveled and project 
a little beyond those of the male blade, an arrangement by which the folds 
of the bladder are less likely to be pinched. 
Fig. 1386. 
The most complete lithotrite, however, in use at present is that of Sir 
Henry Thompson (Fig. 1386), the principal features of which are the cylin- 
Sir Henry Thompson's lithotrite. LITHOTRITY. 
653 
drical handle and the convenient position of the button, by which the instru- 
ment can be thrown into or out of gear when in use. 
There are other forms of lithotrite blades, as the fenestrated (Fig. 1387), 
the flat (Fig. 1388), and the wedge-shaped (Fig. 1389). 
Fig. 1387. 
Fig. 1388. 
Fig. 1389. 
In the fenestrated lithotrite the female blade is slit, and the male blade 
having teeth passes into the former. Though a powerful instrument, it is a 
dangerous one, as the mucous membrane of the bladder may be seriously 
damaged by entering the fenestra and becoming lacerated by the male blade. 
The fragments also which result from its use have sharp edges or angles, 
which are liable to damage the bladder. The flat-bladed lithotrite is open 
to the same objection as the fenestrated in reference to the liability of the 
mucous fold of the bladder to be pinched. 
Cases suited for Lithotrity.-In the selection of cases adapted for the 
operation of lithotrity we must take into consideration the composition, 
number, and size of the calculi, and the age and peculiarities of the patient. 
Stone.-Uric acid and phosphate stones, having usually a soft texture, are 
best suited for crushing, unless several large concretions are believed to exist 
or the size of the calculus is too great. When the latter exceeds in bulk 
the dimensions of a hulled walnut, it will be most prudent to decline the use 
of the lithotrite; and the same course should be adopted in cases of oxalate of 
lime calculi, even though not exceeding the size of a hickory-nut. Lithotomy 
in cases of this kind will be both wiser and safer. 
Patients.-With reference to the subjects of operation, children, who 
always do well when lithotomized, should be excluded from the category of 
cases adapted for crushing. The entire urinary tract requires to be sound 
in order to render the use of the lithotrite successful. Thus, stricture of the 
urethra will prove a bar to the operation unless the coarctation has been first 
thoroughly dilated; and so will an irritable, contracted, or highly-inflamed 
bladder, which refuses to retain a moderate amount of urine. This must not 
be construed as excluding crushing in cases of a chronically-inflamed bladder, 
as few persons suffering from stone of any kind escape this condition. A 
highly irritable urethra, one which habitually resents the passage of a sound, 
either by th/3 urethral fever which follows its use, or by attacks of epidid- 
ymitis, will be unfavorable to lithotrity. Tumors, of whatever nature, malig- 
nant or benign, whether derived from the prostate or arising independently 
in the neck of the bladder, are incompatible with the use of the lithotrite. 
The sacculated bladder is also unfavorable for crushing, as fragments of the 
stone when broken are liable to enter the pockets. 
Extensive disease of the kidneys or ureters always contra-indicates the 
operation of crushing. Too much weight cannot be given to this maxim. 
I have seen three patients die within twenty-four hours after breaking a 
stone, from suppression of urine. 
Atony or paralysis of the bladder does not preclude crushing, though 
more than ordinary care must be observed in the manipulations, as the dimin- 
ished sensibility of the organ exposes it to injury without any complaint being 
made by the patient. 
In females, when the stone cannot be extracted from the bladder through 
the dilated urethra, crushing is indicated. 
Fenestrated lithotrite. 
Flat-bladed lithotrite. 
Wedge-shaped lithotrite blades. 654 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Treatment preparatory to Lithotrity.-This consists in allaying any 
severe irritation of the bladder, such as belongs to what is commonly termed 
a "tit of stone," and which is often induced by the jolting, exposure, or ir- 
regularities of diet incident to travel. A few days' rest in the recumbent 
position, a warm flaxseed-meal poultice over the perineum, the genital organs, 
and the hypogastrium, a warm-water enema to dislodge any fecal accumu- 
lations in the lower bowel, followed by an opium suppository, and the free 
use of alkaline diluents, constitute the leading details of treatment, and 
rarely fail in the course of two or three days to subdue any unusual per- 
turbation of the bladder. Even when no aggravation of vesical symptoms is 
present, I deem it a salutary practice not to operate on patients who are just 
off a journey until they have had the benefit of one or two days' rest. When 
the signs of unusual irritation have disappeared, the sound may be intro- 
duced into the bladder, with the twofold object of searching for the stone 
and determining the capacity and tolerance of the canal for instruments. 
It may be necessary in some instances, by the use of graduated bougies, to 
dilate the urethra, so as to admit with ease the lithotrite; though this is not 
often demanded. The external meatus, which is sometimes found unnatu- 
rally contracted, may require a preliminary treatment of this kind, and 
sometimes incision. 
Operation.-Lithotrity is an operation which demands great tact, gentle- 
ness, precision, and delicacy of movement, with concentrated attention on 
the work in hand. Though it is neither so bold nor so brilliant in effect as 
the operation of lithotomy, I think the art of crushing safely a vesical cal- 
culus requires a much higher order of manual skill than is ordinarily displayed 
in lithotomy. 
In adjusting the patient for lithotrity, he may be placed on a table covered 
with a folded comfortable, and with a low pillow under his head; or he may 
lie across the bed, with the hips resting on its edge, and the feet supported 
on a stool or chair, the limbs being somewhat drawn up and separated from 
each other. The room should be warm, and both the body and extremities 
well protected by sufficient covering, in order to avoid all occasion of chill. 
If the patient has not been able to retain his urine for an hour before 
the operation, three or four ounces of tepid water or thin flaxseed-tea should 
be injected into the bladder. The propriety of administering an anaesthetic 
must be determined by the sensibility of the patient, or by his ability to bear 
a certain amount of uneasiness or discomfort, seldom rising to severe pain. 
If, however, the individual prefers to be unconscious to the entire proceed- 
ing, the anaesthetic need not be withheld. 
The operator, standing on the side most convenient to himself, takes the 
lithotrite, previously warmed and well oiled, and, entering it horizontally into 
the urethra with one hand while the penis is held by the other, passes it 
steadily, almost by its own weight, along the canal, depressing slowly the 
handle of the instrument as the membranous portion of the urethra is ap- 
proached, until the blades glide under the arch of the pubes and enter the 
bladder, the handle of the instrument being now between the thighs. Having 
reached the bladder, the next step is to discover and seize the stone. 
Probably on entering the viscus the point of the lithotrite will come in 
contact with the calculus, which will be known by the sensation commu- 
nicated to the hand. Raising now the handle of the lithotrite, and holding 
it after the manner illustrated in Fig. 1390, one hand grasping the cylinder, 
and the other the wheel at one end of the handle, which moves the male 
blade, the latter is drawn out some distance, and then pushed back, when most 
probably the stone will be caught between the jaws of the instrument. (Fig. 
1391.) 
If this is the case, the button on the handle is to be slid back, which con- 
verts the sliding into the screw movement; then, by turning the wheel, the 
concretion will be crushed into pieces as the blades are forced together. 
This done, the button is to be slid forward. This releases the male blade, LITHOTRITY. 
655 
which should now be drawn out and again closed, -when one of the broken 
fragments may be caught and crushed, in the same manner as was done with 
the entire stone. This process may be repeated two or three times, when the 
jaws of the lithotrite are to be closed and the instrument withdrawn from 
the bladder. 
It may happen that when the lithotrite is introduced into the bladder, and 
its blades are separated and closed, as above described, no calculus is caught. 
Fig. 1390. 
Manner of holding the lithotrite as its blades are about to be separated. 
Then the handle of the instrument should be carried somewhat to one 
side, and the blades opened and closed as in the first instance. Failing 
Fig. 1391. 
Second position of holding the lithotrite ; the stone caught between the blades, and raised before being crushed. 
again to catch the stone, the point should be directed towards the opposite 
side, and the movements of the blades be repeated. If still unsuccessful, 
the search should next be made in the bas-fond of the bladder, or behind and 
below the prostate body. To accomplish this manoeuvre, the handle of the 
lithotrite should be depressed, and the instrument turned half-way round, so 
that the jaws shall be reversed and directed downward. If in this position 
the blades are opened and closed, the stone will usually be caught, when the 
instrument must be turned to the first position, with the blades directed 
upward; then by turning the wheel the concretion will be crushed without 
endangering the walls of the bladder. 
The object in these procedures is to seize and break the stone with as few 
movements of the lithotrite as possible. In most instances, if due gentleness 
is practiced, and the bladder not provoked to resistance, the calculus requires 
not to be sought for,-rather it falls into the jaws of the instrument. 
Other methods of manipulating the lithotrite have been employed, and 
may, when the former fail, be adopted. That of Heurteloup, copied by 
Brodie, and at one time known as the English method, consists in introducing 
the lithotrite in the manner already described, and when well into the blad- 
der elevating the handle so as to bring the convex surface of the blades in 
contact with its posterior wall behind the prostate body, and while the male 
blade is being drawn out and again pushed back, at the same time pressing 
the female blade towards the rectum, in order that the calculus may roll in 656 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
between the jaws of the instrument. Should this not occur, the lithotrite, 
still held in the bas-fond, may be tapped with the hand, first on one side and 
then anteriorly, the impulse from which reaching the bladder will tend to 
cause the stone to drop from its resting-place into the jaws expanded for its 
reception. 
If still unsuccessful, the closed instrument may be turned very slightly to 
one or the other side, thus placing the blades in a position somewhat oblique 
to the antero-posterior axis of the body, when they may again be opened 
and closed with the hope of catching the concretion. 
Civiale's plan of manipulation differs somewhat from that detailed. The 
lithotrite is carried well into the bladder, and should its curved extremity 
in passing onward touch the stone the operator moves a little either to the 
right or to the left, with a view to ascertain the position of the calculus. 
After this is recognized, the instrument should be carried slightly in the 
opposite direction from that occupied by the stone, and while pressing the 
female blade towards the rectum the male blade should be slowly withdrawn ; 
after which the jaws of the lithotrite are to be inclined in the direction of 
the concretion, which will probably fall into the trap set for its reception. 
Large calculi are almost invariably found near the neck of the bladder, 
immediately behind the prostate, and are usually touched by the lithotrite 
as it enters the organ. When this is the case, the stone is most certainly 
caught by pushing the female blade onward while the male blade is held 
fixedly in position. The jaws being now separated, let the instrument be 
withdrawn a trifle and turned slightly on its axis towards the stone, when by 
pressing homeward the male blade the calculus will be found to be caught. 
It is propei' to say that no single manipulation or manoeuvre will meet 
every case of vesical calculus, and consequently the surgeon must be familiar 
with all. In my own operations I follow very much the order in which the 
different methods have been described, though in a very large proportion of 
cases I find the one first noticed to answer the object in view. A calculus, 
on account of its small size and its position close to the neck of the bladder, 
may successfully elude the grasp of the lithotrite. Under these circum- 
stances the hips of the patient will require to be raised, by placing a cushion 
underneath the pelvis, so as to roll the stone back, and thus not only enlarge 
the field of exploration but place the concretion in a more accessible location. 
The same position will often be necessary when searching for fragments in 
secondary operations. 
Cautions.-There are several injunctions which cannot be too strongly ob- 
served in performing lithotrity. First, no jerking, uncertain, or rapid move- 
ment of the instrument is allowable while it is being manipulated in the 
bladder; secondly, the lithotrite should be held firmly in one position while 
the male blade is being moved, and at a point sufficiently removed from the 
centre of the bladder to prevent the aforementioned blade from striking 
the neck of the organ, an accident which is always to be deprecated ; thirdly, 
when a stone is once caught the instrument should be moved a little in dif- 
ferent directions before applying the crushing power, in order to ascertain 
that no portion of the bladder is included in its grasp. 
What amount of work it is proper to do in the bladder at a single sitting 
is a question not easily answered. The rule has been with many operators 
after breaking the stone to crush two or three fragments, and with this to 
be content. There is, however, a growing tendency to carry this process of 
reducing the calculus to a much greater extent, and even, as I shall presently 
describe, to complete the entire work at a single sitting, including the re- 
moval of all debris from the bladder. Modern surgery is, I think, in certain 
directions rather too bold. There is a disposition to carry instrumentation a 
little beyond the solid ground of safety. I do not propose to enter a protest 
against all innovations on the old usages of our art, but only to utter the 
caution that it is wise to " hasten slowly," and to move circumspectly until a 
sufficient number of facts or observations have been accumulated to justify a LITHOTRITY. 
657 
sound deduction, or on which to found a safe rule of practice. As to the length 
of time during which the lithotrite may properly be retained in the bladder, 
much will depend on the tact of the operator, and on the previously ascertained 
tractability of the urinary passages under the use of instruments, as the 
sound or the bougie. A surgeon who has been trained by long experience 
in the use of the lithotrite may prolong the work of crushing a calculus to a 
period far beyond that which would be proper in one who has only at con- 
siderable intervals of time performed the operation. The latter will prob- 
ably do more harm to the bladder in a minute than the former would inflict 
in half an hour. The amount of instrumentation, therefore, which may be 
proper in the hands of an experienced lithotritist may be highly improper 
in those who enjoy fewer opportunities for executing such operations; and, 
as all persons laboring under stone cannot command the highest order of 
skill, prolonged crushings are generally to be condemned. 
If after exploration of the bladder preliminary to an operation the patient 
suffers from chills, urethral fever, and much vesical irritation, the first crush- 
ing should be brief, and limited to breaking the stone, not to pulverizing the 
fragments, by which the temper of the bladder can bo tested. The same 
course should be adopted in eases where it is necessary to turn the end of 
the blades of the lithotrite towards the trigonum vesica? in order to catch the 
concretion, as the walls of the bladder under these circumstances are more 
likely to sustain injury than when the stone is more favorably located. The 
same rule will apply to cases of old men with great enlargement of the 
prostate body. 
When the bladder manifests no unusual irritability and the calculus is soft 
and does not exceed much in size a hickory-nut, it may be safely disposed of 
at a single sitting. If, on the contrary, the stone is of greater magnitude 
and of very hard consistence, and the bladder is unwilling to retain the urine 
or the water injected, it will be unsafe to persevere in the pulverization of 
the fragments beyond eight or ten minutes. There is an advantage in 
always using two instruments,-first a large and strong one adapted to 
breaking the calculus, and afterwards a more delicately-constructed one to 
reduce the fragments. Water should be drawn with a soft catheter, in order 
that the bladder may be at rest and no fragments be immediately passed to 
add to the irritation; after which the patient should be placed in bed and 
covered up warm, a suppository consisting of two grains of opium with half 
a grain of belladonna introduced into the rectum, and a warm flaxseed 
poultice applied over the hypogastrium, the genitals, and the perineum. 
The diet for the first three days must be restricted to milk and bread; after 
which, if no unusual symptoms arise, a moderate amount of solid food may 
be allowed. 
During the first twenty-four hours the patient should not be allowed to 
rise in order to pass the urine. By refraining from urination the neck of 
the bladder will escape to some extent the irritation of sharp fragments 
which in the perpendicular posture would fall against it, and time will be 
allowed for some smoothing off of angularities and edges. After this pre- 
cautionary period is past he may empty the bladder in the standing posture, 
and should be directed to drink freely of some diluent, such as barley-water, 
which tends to favor the expulsion of the detritus. In order to collect the 
debris, the urine should be passed through a piece of fine tarlatan stretched 
over the urinal, which will serve to separate it from the water. Should no 
complications follow, the operation can be repeated in from three to eight 
days. It is a good rule, and one equally applicable to both the first and the 
second crushing, always to confine the operation to that part of the bladder 
where the stone or its fragments are first found, without shifting the in- 
strument from place to place. The debris manifests a strong disposition to 
keep together. 
Professor Bigelow, of Boston, more bold in his procedure, not only attacks 
large and hard stones wTith the lithotrite, but carries the process of crushing 
vol. ii.-42 658 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
at a single sitting to an extent limited only by the time necessary for the 
complete comminution and pulverization of the calculus. The work may oc- 
cupy one or two hours, and is immediately followed by the extraction of the 
debris. The method of this distinguished surgeon he has named litholapaxy. 
The lithotrite used for the purpose is larger and more powerful than the 
instruments in common use. The floor of the female blade is somewhat 
elevated, and the male blade, in addition to a central septum at the heel, 
has lateral triangular notches. The female blade is also furnished with a 
slot, which receives the spur at the heel of the male blade. (Fig. 1392.) The 
alternations of the triangular notches tend 
to prevent the impaction of the jaws of 
the instrument with debris. 
Management of the debris.-There are 
two plans of disposing of the fragments 
produced by crushing. By one their dis- 
charge is left to natural processes,-that 
is, to come away with the urine during 
voluntary efforts at micturition ; by the 
other they are extracted at once with an 
evacuating apparatus. 
Those who adopt the first plan think 
that by allowing the coarser particles of 
the debris to remain for twenty-four or 
more hours in the bladder the sharp an- 
gularities and edges will be worn away, 
and thus that the bladder and the urethra 
will be less exposed to injury during their expulsion. On the other hand, 
those who prefer the immediate removal of the fragments believe that the 
sooner they are dislodged from the bladdei' the better, and that the contact 
of their sharp points with the mucous coat of the bladder is calculated to 
do more harm than would ensue from their forcible extraction. 
The latter was the opinion of Sir William Fergusson, and, with certain 
limitations, it is also that entertained by Sir Henry Thompson. 
Method of removing debris.-Sir William Fergusson effected the extraction 
of the fragments by the use of a small scoop. A better apparatus, however, 
is that of Clover. This consists of an elastic bottle with a glass reservoir 
attached, into which a large catheter, with an ample concave eye, is fitted. 
The catheter is first introduced into the bladder and the urine drawn off. 
The bottle, being now filled with warm water, is connected with the tube, 
and alternately compressed and relaxed; the fluid is forced into the bladder, 
and returns as the bulb expands, bearing on the reflex current a quantity of 
debris, which is deposited in the glass cylinder. (Fig. 1393.) Interruption 
Fig. 1392. 
Professor Bigelow's lithotrite. 
Fig. 1393. 
Evacuating apparatus of Clover. 
or stoppage of the stream will indicate the entrance into the catheter of a 
fragment which is too large to pass through, and which must be dislodged LITHOTRITY. 
659 
or driven back into the bladder by forcibly impelling the liquid in the reversed 
direction. 
Dittel's apparatus.-Another evacuating appliance is that of Professor 
Dittel, which consists of a large-sized catheter to which is fitted an attach- 
ment having three limbs,-one the catheter limb, a second an outflow limb, 
and the third a syringe limb. At the place where these three limbs come 
together there is a valve-arrangement similar to that used in the stomach- 
pump. To the outflow branch a flexible rubber hose, several feet in length, 
is attached, the free end resting in a vessel on the floor some distance below 
the patient. As the water is thrown through the syringe branch into the 
bladder, it returns through the outflow limb into the hose, the latter con- 
stituting the long limb of the siphon. 
Colin's evacuator, rarely, if ever, seen in this country, is formed of the 
following parts: a catheter of large calibre and short curve, a glass cylinder 
with an opening before and behind, and an air-pump, the piston of which is 
moved by means of a toothed wheel acting on a dentated bar. When em- 
ployed for removing the detritus of a stone, a few ounces of warm water are 
injected into the bladder through a catheter, the end of which is afterwards 
fitted into one of the openings in the glass 
cylinder, while the end of the suction-pump 
is introduced into the other, and the contents 
of the bladder are drawn out by working the 
piston. 
Bigelow's evacuator consists of a large elastic 
bulb having a glass bottle at one extremity, 
and a piece of rubber tubing two feet in 
length at the other. The evacuating catheters 
are either straight, or slightly curved near the 
vesical extremity, and of large size (Nos. 28 
to 32 of the French scale). (Fig. 1394.) In 
using this apparatus, the bulb is charged with 
warm water; after introducing into the bladder 
one of the catheters and establishing a con- 
nection between the two at the end of the 
flexible tube, the evacuating-tube is pressed 
firmly against the bas-fond of the bladder, so 
as to invite the fragments towards the open 
orifice at its end, the bulb is compressed, and 
a stream of water is forced into the organ. On 
removing the pressure, the expansion of the 
bulb invites a reflex current, which carries 
with it the broken fragments of stone and 
deposits them in the glass bottle. This is to 
be repeated until all debris has been extracted 
from the bladder. If during this operation 
the tube becomes obstructed by a fragment 
too large for its canal,-an occurrence which 
may readily be detected by an unequal and 
slow expansion of the gum bottle,-it can be 
cleared by waiting until the latter has become in a great measure distended 
and then forcibly compressing the bulb and driving back the obstruction 
before the column of water. 
The exact value of instrumental evacuation is by no means a settled ques- 
tion. That it is capable of great abuse cannot for a moment be doubted. A 
current of water forcibly pressed into a bladder containing a large number 
of fragments bristling with sharp points may, by driving the latter against 
the lining membrane of the viscus, produce minute lacerations, which will 
lay the foundation for traumatic cystitis. Again, some of these fragments 
are likely to be forced into the little pouches which so often exist in the ribbed 
Fig. 1394. 
Bigelow's evacuating apparatus. 660 
INJURIES AND DISEASES OE THE GENITO-URINARY ORGANS. 
bladders of persons who have long suffered from vesical trouble, and in this 
way occasion relapses by subsequently becoming the nucleus for another 
stone. It must have been observed how patients groan and struggle, even 
when under an anaesthetic, while the bulbs of these evacuating appliances 
are being compressed and the water forced into the bladder; and this, I sup- 
pose, is due to the propulsion of coarse detritus against the sensitive walls of 
the organ, as no such exhibitions of suffering are witnessed in the ordinary 
injections of the bladder preparatory to operating. If, however, the calculus 
is well reduced or pulverized, there can be no objection to the immediate 
evacuation of the detritus; and for this end the apparatus of Clover or of 
Bigelow answers every purpose, only observing to force the water into the 
bladder in a gentle and continuous stream, and not to prolong the process 
beyond five or six minutes. The subsequent removal of the fragments may 
be left to the operations of nature. 
Complications or sequences.-In cases where the bladder is in a state of atony 
or paralysis, and consequently unable by its own contractility to expel the 
debris incident to crushing a calculus, artificial evacuation of the fragments 
will be demanded. Generally a bladder in this condition, from defective sensi- 
bility, is quite tolerant to protracted instrumentation, whether of crushing or 
of evacuating. 
Again, in cystitis following the use of the lithotrite, it is highly important 
that the fragments should be removed from the bladder at the earliest mo- 
ment, in order that the chief source of irritation may be got rid of; and for 
this purpose the crushing should be renewed and the evacuations effected 
by either a Clover or a Bigelow apparatus. We are indebted to Sir Henry 
Thompson for this practice, the soundness of which has been proved by tbe 
experience of other operators. It is desirable under these circumstances to 
bring the patient under tbe influence of an anaesthetic before performing the 
operation. 
Even though no fragments remain in the bladder, a certain degree of cystitis 
occasionally follows the use of the lithotrite, as will be indicated by frequent 
and painful urination continuing after tbe operation. These are cases which 
demand particular attention to the state of the bladder, to see that no residual 
urine is retained; and this can be determined only by the use of the catheter. 
If after urination a soft instrument is passed, and a quantity of water, even 
though it is small, is drawn away, it will show that the organ does not fully 
relieve itself, and will also indicate the necessity for repeating the catheteriza- 
tion at least once daily. The effect of this will be not only to prolong the 
periods of micturition, but also to remove tbe cystitis, which if allowed to 
continue would cause such deposits (phosphatic) as would lead to the forma- 
tion of another stone. 
Traumatic, or urethral and vesical fever.-Not three or four 
hours after lithotrity, the patient is attacked by a rigor lasting from eighteen 
to twenty minutes, and followed by high fever, with an elevated tempera- 
ture, flushed face, dry, hot skin, and urgent thirst, with pain in the back 
and headache. These symptoms, after one or two hours, pass off with sweat- 
ing, and the patient may experience no inconvenience other than a sense of 
exhaustion. This paroxysm of surgical fever may, in most instances, be safely 
left to the salutary effects of nature. Little is required beyond placing some 
additional coverings on the body, keeping bottles of hot water to the feet and 
along the spine, and allowing the use of some hot lemonade. When reaction 
sets in, a portion of the bed-covering will require to be removed, and the warm 
drinks replaced by cold water or effervescing drinks. The diet must at first 
: be of a non-stimulating nature, as milk, toast-water, or barley-water, and should 
be increased both in quantity and in strength after the febrile perturbation 
•has passed. 
Hemorrhage, though not very uncommon after lithotrity, rarely assumes 
sufficient importance to demand special notice. Should it do so, however, it 
must be managed according to the principles already explained under the LITHOTRITY. 
661 
head of vesical hemorrhage. In one instance Mr. Key, after crushing a cal- 
culus, was, in consequence of the alarming nature of the bleeding, compelled 
to perform lithotomy. 
Orchitis.-Swelling of the testicle occasionally follows the operation of 
crushing a stone, excited either by irritation reflected from the bladder and 
urethra, or, as occasionally happens, from a portion of the calculus lodging 
in the latter canal. Rest in the recumbent position, elevation of the scrotum, 
and the application of a lotion of lead-water and laudanum, a mild laxative, 
and at night a sufficient amount of some anodyne to allay pain and to pro- 
cure rest, constitute the proper treatment. It is best to abstain from re- 
peating the operation until the swelling and undue sensibility of the testis 
have disappeared. If, however, the inflammatory state of the testicle is 
associated with an attack of cystitis, and the bladder has not been cleared 
of its detritus, neither the lithotrite nor the aspirator should be withheld. 
Suppression of urine, following lithotrity is always an alarming occurrence. 
It may ensue either from shock or from some pre-existing renal inflammation 
or degeneration. The remedies are warm poultices around the loins, contain- 
ing the leaves of digitalis, and the free use of alkaline drinks, with quinine 
and milk-punch. 
Pycemia, especially in old subjects who have long suffered from stone, and 
whose health has been broken by chronic cystitis, is a not uncommon result 
of lithotrity, and requires for its treatment quinine, iron, stimulants, and 
concentrated liquid nourishment. 
Perforation of the bladder has happened in a few instances: unless occur- 
ring in a bladder greatly thinned and softened from disease, such an event 
argues a rude and unskillful use of instruments. An accident of this nature 
would give rise to collapse, vomiting, abdominal distention and tenderness, 
and the absence of urine from the bladder, with perhaps the escape of blood 
when a catheter is introduced into that viscus. 
The treatment should be the same as that laid down under the head of 
rupture of the bladder. 
Impaction of fragments in the neck of the bladder or in the urethra is 
one of the common sequels of "crushing." The fact of such an impaction 
having taken place will be sufficiently indicated by the obstruction offered to 
the outflow of the urine, the water escaping either in drops or in several 
small contorted streams. Extraction by the forceps, or, when this is not 
feasible, pushing the body back again into the bladder by a catheter or a 
bougie, as already described when treating of foreign bodies in the urethra, 
is the proper course to pursue. 
Derangement or fracture of the blades of the lithotrite is an exceedingly em- 
barrassing accident. I have known the jaws of the instrument, from some 
defect in the button which fixes or releases the male blade, obstinately to refuse 
to close. In one instance the evil incident to the removal of an instrument 
in this condition resulted in the death of the patient. Should the skill of 
the surgeon not be sufficient to overcome this derangement in the mech- 
anism of the lithotrite, it must be allowed to remain in the bladder until the 
assistance of a surgical cutler can be obtained. Should a jaw break off, its 
extraction by median lithotomy would be required. In addition to the above- 
named sequels of lithotrity there may follow prostatitis, peritonitis, and pelvic 
cellulitis, all of which are to be managed on the general principles which have 
already been discussed under their several beads. 
Results.-What are the results of lithotrity ? This is a question of no 
small importance. Its answer embraces both the subject of mortality and 
the tendency to relapse. The success of the operation varies according to 
the skill of the operator and the method which he adopts. Sir Henry Thomp- 
son reports 422 cases of lithotrity performed by himself, with 32 deaths,- 
that is, 1 in 13, or a mortality of 7.58 per cent. Sir Benjamin Brodie's cases 
of this operation amount to 115, with 9 deaths, or a mortality of 7.74 per 
cent. Sii' William Fergusson in 109 lithotrities had 12 deaths, or 11 per cent. 662 
INJURIES AND DISEASES OF THE GENITO-URINARF ORGANS. 
Keith in 122 cases had 8 deaths, or 6.55 per cent. Mr. Crichton in the same 
number of operations as Keith-122-had precisely the same mortality, that 
is, 8 deaths, or 6.55 per cent. Leroy in 116 lithotrities had 11 deaths, or a 
mortality of 9.48 per cent. Ivanchich in 100 cases lost 13, a mortality of 13 
per cent.; and Porter in 133 cases had 24 deaths, or 18 per cent. The aggre- 
gate of all these operations amounts to 1239, with 117 deaths, or a death-rate 
of 9.42. 
In the Pennsylvania Hospital the recorded operations of lithotrity amount 
to 14, with 2 deaths, or 14.28 per cent. 
Gross in a collection of 1470 lithotrities found 159 deaths, or 10.81 per cent. 
Any comparison instituted between lithotrity and lithotomy with a view 
to determine the comparative mortality of the two operations would lead to 
very erroneous conclusions adverse to lithotomy, simply because the cases 
which are subjected to crushing are all selected,-they must be of a certain 
character as to age, organic soundness, size, and composition of the stone,- 
while in lithotomy the cases are taken indiscriminately, the unfavorable with 
the favorable. There is one class of calculous patients, namely, children, 
wThich is excluded from the domain of lithotrity as entirely unsuited for this 
operation, but which is eminently well adapted to lithotomy; and, from the 
numerical superiority of this class, a very large proportion of all cases of 
lithotomy are performed on children, and with almost uniform success. It 
is in adults that lithotrity makes its greatest conquests, and it is among adults 
that lithotomy sustains so many defeats. Sir Henry Thompson has analyzed 
723 cases of lithotomy performed on the above class of persons, of which 
number 1 in 4.82 proved fatal; whereas in a like number of lithotrities in 
the same class, taken from the practice of English and American surgeons, 
the deaths will not exceed 1 in 14 patients. 
The tendency to relapse is unquestionably much greater after lithotrity 
than after lithotomy. This results from that last fragment which in lithotrity 
is liable to elude detection, and w'hich becomes the nucleus for another 
stone. In the cases of calculus treated by Thompson by crushing, this 
occurred as often as once in every twelve cases, and in the experience of 
Civiale once in every ten cases; while, as nearly as can be determined from 
accessible data, a recurrence of stone after lithotomy does not occur often er 
than once in every 57 cases. Professor Gross has had but three instances of 
such relapse in 140 cases of lithotomy. This is a remarkable experience. I 
do not know the after-results of all my own lithotomies, but I can speak con- 
fidently with regard to the history of fifty cases, three of whom had relapses. 
One of these, a child, should, however, be excluded from this category, as 
the ureter was greatly dilated and contained a number of calculi, one of the 
concretions at intervals dropping into the bladder. The other two cases 
w'ere men advanced in life, both laboring under a severe cystitis, to which 
I attributed the recurrence of stone, the concretions being made up chiefly 
of the phosphate of lime. 
Or we may compare the operations of crushing and cutting as practiced 
by the same surgeon. Sir Henry Thompson reports having performed 422 
lithotrities, with 32 deaths, or 1 in 13 cases, and 78 lithotomies, with 29 
deaths, or 1 in 2f cases. Very similar results appear to have been attained 
by Sir William Fergusson. Of the 271 cases of stone which came under the 
care of this eminent surgeon (217 of which were adults), 109 were treated 
by lithotrity, with 12 deaths, while of 110 subjected to lithotomy 32 died. 
If, however, a comparison is drawn between lithotrity and lithotomy as 
employed on all ages and conditions of subjects, the mortality will be found 
on the side of the former operation. 
Lithotomy. 
Lithotomy, or the extraction of stone by cutting, is one of the most impress- 
ive operations in surgery. It demands not only the utmost precision and LITHOTOMY. 
663 
care for its execution, but also an unusual degree of self-possession and bold- 
ness of purpose. The pupils of Hippocrates were compelled by their master 
under a solemn oath to promise that they would never perform the cutting 
operation for stone. Lithotomy at this time was in the hands of men who 
possessed not a single qualification for its execution except fearlessness, and 
so great was the anatomical ignorance of these itinerants that the mortality 
following the procedure was frightful. 
Four different plans were originally employed for the extraction of stone. 
The first is often termed the method of Celsus, from its having received the 
sanction of that distinguished physician, though the operation has been 
known for at least two thousand years. This plan is often described as lith- 
otomy by the apparatus minor. The second method is the Marian, or that by 
the apparatus magnus, as performed by Marianus Sanctus. The third method 
is the sectio hypogastrica, or that by the apparatus altus, practiced originally 
by Peter Franco, in which the stone was removed through the abdominal 
walls above the pubes, at present better known as supra-pubic lithotomy; 
and the fourth, or most recent plan, is the lateral section of the perineum, 
devised by a French monk, Frere Jacques, and introduced to the profession 
during the latter part of the seventeenth century. 
The Celsean method, more properly that by the apparatus minor, received its 
latter name from the very few instruments required for its performance. The 
patient, when an adult, had the hands and feet secured together and held by 
strong assistants; if a child, he was supported on the knees of an assistant, 
who, while seated on a chair, passed his hands beneath the limbs and grasped 
with a firm grip the wrists of the little one. The operator, having anointed 
the forefinger of the left hand with oil, introduced it into the rectum of the 
patient and carried it forward towards the prostate, while with the right hand 
pressed strongly above the pubes he endeavored to touch the stone through 
the walls of tlie bladder, on doing which it was pushed over to the left side of 
the viscus, whence it was dragged forward by the finger in the rectum, so as to 
form a visible prominence on the left side of the perineum. It was then cut 
down upon by a bistoury, the structures being divided regularly inward. As 
soon as the opening was made into the bladder, the calculus was thrust out 
through the wound by the finger which held it against the perineum; or, if 
too voluminous to be extracted in this manner, it was drawn out by a hook. 
This operation, from the manner in which it was done, was not improperly 
termed " cutting on the gripe." 
The method by the apparatus major, believed to have been first devised by 
Franciscus de Romani, an Italian physician of celebrity, who lived at Cre- 
mona, was subsequently improved by one of his pupils, Marianus Sanctus, and 
hence has been called the Marian method. A steel catheter, having a groove 
in its convex surface, was passed through the urethra into the bladder, and 
its vesical extremity turned towards the left side of the perineum, where it 
was held by an assistant, while the surgeon made an incision (in the middle 
of the perineum, corresponding to the raphe between the scrotum and the 
anus) with a broad, lancet-shaped scalpel, part of the knife being wrapped 
with a piece of muslin. The tissues were divided until the catheter was 
reached in the membranous portion of the urethra. The latter being next 
opened, and the groove of the staff exposed, the incision was continued as 
far back as the prostate gland, after which a male conductor was fitted to the 
groove and carried onward into the bladder, when the catheter was with- 
drawn. A female conductor was next passed into the viscus, and the neck 
of the bladder dilated by separating the handles of the two instruments. As 
soon as the dilatation was carried to a sufficient extent, a pair of forceps was 
introduced into the bladder between the two conductors, and the stone ex- 
tracted. Other operators, instead of employing the male and female con- 
ductors, passed along the groove of the catheter a gorget, which as it entered 
the bladder not only stretched the neck of the organ, but also acted as a 
guide for the introduction of the stone forceps. Originally, the neck of the 664 
INJURIES AND DISEASES OF THE GENITO-URINARF ORGANS. 
bladder in this operation was divided instead of being dilated. The ex- 
traction of the calculus was also effected in many instances by a spoon-shaped 
scoop and a finger. 
Hypogastric operation.-This operation has been variously named,-as that 
by the apparatus altus, the high operation, the hypogastric section, the 
methodus Franconica, and more recently the supra-pubic. This method is 
attributed to a French surgeon named Peter Franco. His first operation 
of this nature was done on a patient at Lausanne, Switzerland, in 1560, not 
of choice, but from an inability to extract the stone through the perineum 
in consequence of its great magnitude. The operation fell into disuse, but 
was revived by Douglas in England, and also advocated in France, in 1727, 
by Morand, from which time to the present it has been alternately praised 
and condemned. The bladder is exposed in this operation by cutting through 
the linea alba immediately above the pubes and opening the fundus of the 
organ anterior to its peritoneal investment. 
Lateral lithotomy, which at present is so generally practiced, is sup- 
posed to have been devised by Peter Franco, about the middle of the six- 
teenth century. In the latter part of the seventeenth century, or about the 
year 1697, an obscure monk, named Frere Jacques, created a great sensation 
on the continent of Europe as a lithotomist. This man came to Paris in a 
state of absolute poverty, announcing to the public that his object was to 
instruct the French surgeons in a new method of cutting for stone. His 
first application was made to the physicians and surgeons of the king, to 
be allowed to operate on a patient suffering from calculus, at the same time 
backing his application by the certificates of many persons who were repre- 
sented as having been cured under his hands. From the entire absence of 
all mercenary considerations on the part of this monk, who, it appears, 
received no compensation beyond what was necessary to keep in repair 
the instruments used in the operation, and from the novelty of the whole 
affair, Frere Jacques was permitted to demonstrate his method on the cadaver, 
properly prepared, before many of the distinguished surgeons of Paris. The 
body was secured in the usual lithotomy position, and a catheter introduced 
into the bladder, with which he made the perineum somewhat prominent. 
A knife, somewhat longei' than an ordinary bistoury, was next entered be- 
tween the anus and the tuberosity of the ischium on the left side of the peri- 
neum, and the parts divided upward until, guided by the catheter, the neck 
of the bladder was opened. Then, passing a finger through the wound into 
the bladder, and finding the position of the improvised calculus, he first passed 
an instrument like a spoon or a scoop, which served as a guide for the 
forceps, conducted them readily into the organ, and quickly seized and 
extracted a large stone. Notwithstanding that the cadaver was afterwards 
carefully examined by the physicians and surgeons then present, and the 
incisions found to have passed through the triangle formed by the accele- 
rator urinse, the erector penis, and the transverse perineal muscles without 
inflicting any injury either upon these structures or upon the blood-vessels, 
and that the neck of the bladder had been properly opened, these gen- 
tlemen were unwilling to allow this itinerant lithotomist to operate on the 
living subject. Undeterred by this refusal, the monk presented his appli- 
cation and testimonials to the king's physicians and surgeons residing at 
Fontainebleau, praying that he might be allowed to operate on a patient 
whom he had found at that place suffering from stone. The request was 
granted, and the operation executed, it is said, with the same dexterity as 
had been exhibited on the cadaver in Paris. The effect of all this was, in 
the course of the following year, the procuring of a license from the king, 
on the strength of which he returned to Paris and cut a large number of 
patients afflicted with calculus. By this time so notorious had Jacques be- 
come that on the occasion of his operations the crowd which attended was so 
large that it was found necessary to detail a guard of soldiers to preserve the 
required order. When the results of these operations were ascertained, it LITHOTOMY. 
665 
was found that many of the patients died, and that those who escaped with 
their lives were left with fistula and other serious sequels. In some the 
bladder was entirely severed from the urethra, and in others the rectum wTas 
opened,-all going to show that Jacques was utterly devoid of anatomical 
knowledge. He never employed any treatment either before or after his 
operations, and showed his ignorance, rashness, and inhumanity, when de- 
sired by his patients to attend to their wounds, by saying that it was 
sufficient for him to have extracted the stone: it wTas God's work to cure 
them. Notwithstanding his recklessness, the operations of Jacques were 
instrumental in attracting the attention of learned surgeons to the method 
employed, as one which, in the hands of men well instructed in the surgical 
anatomy of the perineum, and with proper instruments, might prove of the 
utmost value. We find that Marechai in France, and Rau in Holland, 
by substituting for the hollow tube of Jacques a grooved catheter, made a 
valuable improvement. They were in the habit of making their incisions on 
one side of the perineum, and extracting stones with marked success. It 
is to an English surgeon, however, that we are indebted for the perfection 
of lateral lithotomy. Up to the time of Cheselden most operations for stone 
were performed either by the Marian or by the supra-pubic method. This 
surgeon, having heard of the plan employed by Frere Jacques and by Rau, 
carefully improved the instruments and adopted such other measures as were 
necessary for reaching the bladder with safety, finally systematizing and 
perfecting the operation now generally known as lateral lithotomy. So great 
was the success of Cheselden in this department of surgery that Morand 
was sent to London from Paris to witness his operations, and after his return 
made so favorable a report to the French Academy that the method of the 
distinguished surgeon of St. Thomas's Hospital was generally adopted. 
Perhaps no man since the days of Cheselden, with a single exception, Sir 
Henry Thompson, has attained an equal success. Of 213 patients whom he 
cut, of all ages, only 10 died. Sir Henry Thompson in 51 lithotomies done 
on elderly adults lost not a single case. 
In addition to the operations already named, there are the bilateral, intro- 
duced by the celebrated Dupuytren in 1816; the median, inaccurately spoken 
of as a revival of the old Marian plan, and suggested by Manzoni, of Verona, 
Italy, in 1808, in 1825 patronized in England by Mr. Allarton, and in this 
country practiced to some extent by the late Dr. Walters, of Pittsburg; the 
medio-bilateral, advocated by Civiale; and the recto-vesical, devised by Sanson 
in 1816, all of which will be described in their proper order. 
Preparation of the Patient.-Whatever operation may be determined 
on, it is highly important that the subject undergo some preparatory treat- 
ment. The first question to be decided is the fitness of the individual for 
any operation. The fact that the health of a patient laboring under calculus 
has in consequence of long-continued vesical irritation been seriously im- 
paired is no bar to an operation, provided there is no evidence of organic dis- 
ease of internal organs; on the contrary, such persons when relieved from the 
local irritation often recover very rapidly after lithotomy. Very different, 
however, is it with those who suffer from disease of the kidneys, dilated 
ureters, pulmonary consumption, and advanced structural alteration of the 
heart. Under these circumstances it is best to decline an operation alto- 
gether, as being attended with too great risk to life, and to dictate a course 
of treatment best adapted to the condition present. Again, the patient may 
be far advanced in life, and the stone one of great magnitude, when it is 
desirable that no operation shall be performed, the surgeon contenting him- 
self with the use of those remedies which are calculated to mitigate the 
evils of the situation. Rest, alkaline or acid diluents (as the constitution of 
the water may suggest), a carefully-regulated diet, and an occasional even- 
ing suppository of opium, will not unfrequently secure such relief that life 
will not be materially, if at all, shortened. When the general health of the 
patient is sound, little more is required than three or four days of absolute 666 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
rest, some laxative medicine, and a somewhat restricted diet (using meat only 
once a day during the preparatory period), and, if much disturbed at night 
from bladder-irritation, the introduction into the bowels at bedtime of a sup- 
pository of opium and extract of hyoscyamin. On the evening preceding the 
day of operation the bowels must be cleaned out by a dose of Rochelle salt 
or castor oil, and after the action of the medicine an anodyne administered, 
either of morphia, opium, or deodorized tincture of opium. 
Lateral Lithotomy. 
In lateral lithotomy the division of the tissues is made on the left side of 
the perineum, extending inward through the prostate gland and the neck of 
the bladder. 
Surgical anatomy.-A brief description of the surgical anatomy of the parts 
concerned in lateral lithotomy will contribute to the proper understanding 
of the subject. 
The perineum, from being a mere fissure when the limbs are together, 
becomes an ample space when the legs and thighs are flexed and strongly 
abducted. It is equally divided by a dense line, the raphe, which extends 
from the scrotum to the anus. When the skin and superficial fascia are 
turned aside, a layer of adipose tissue is seen to fill up the fossae-ischio- 
rectal-which exist between the sides of the rectum and the tuberosities of 
the ischium, and through which run branches of the inferior hemorrhoidal 
arteries, veins, and nerves. 
If this mass of fat is removed from the ischio-rectal fossae, the latter cavi- 
ties will be found to be lined on all sides by fasciae,-on the outside by the 
obturator, on the inside by the levator ani, and in front by the middle perineal 
fascia. The last-named fascia covers in the corpora cavernosa and corpus 
spongiosum of the penis, is attached laterally to the rami of the ischium and 
pubes, and posteriorly passes round the transverse perineal muscles and dips 
inward to become continuous with the deep perineal fascia or the triangular 
ligament. It is this deep prolongation of the fascia which separates that por- 
tion of the outlet of the pelvis nearest to the rectum from that part which con- 
tains the penis and urethra: hence the division of the perineum into urethral 
and anal. If this middle perineal fascia is divided vertically along the middle 
of the corpus spongiosum and transversely towards the ischium, and is turned 
off from the subjacent structures, there will be exposed anteriorly the accel- 
erator urinse muscles covering the bulb of the corpus spongiosum, the erector 
penis on each side overlying the crura of the corpora cavernosa, and, run- 
ning across the perineum, the transverse perineal muscles. The last-named 
muscles, together with the accelerator and the sphincter ani, converge to form 
the perineal centre. The relations of the acceleratoi' urinae, erector penis, and 
transversus perinaei muscles are such that a triangular space is formed lying 
between the penis and the ascending ramus of the ischium; at the bottom of 
this lies the triangular ligament, a membrane consisting of two layers placed 
beneath the pubic arch, and between which are situated the membranous 
portion of the urethra, the compressor urethrae muscles, the glands of Cowper, 
and the artery of the bulb, the latter being near the apex of the muscu- 
lar triangle just referred to. This artery is a branch of the internal pudic, 
which runs along the inner surface of the ramus ischii near its inner border 
and covered in by the obturator fascia. Immediately behind the deep or pos- 
terior leaf of the triangular ligament are the prostate body and the neck of 
the bladder. Fig. 1395 will serve to illustrate the above description of the 
male perineum. 
Parts divided.-The structures divided in lateral lithotomy are the skin, 
superficial fascia, lower oi' external hemorrhoidal vessels and nerves, the 
posterior fibres of the accelerator urinae and transversus perinaei muscles 
with the middle perineal fascia, transverse perineal vessels, and often also 
the superficial perineal vessels and nerves, a few of the anterior fibres of the LATERAL LITHOTOMY. 
667 
levator ani and compressor urethrre muscles, the membranous and prostatic 
portions of the urethra, and the prostate body. 
Operation.-For the operation of lithotomy there is required a narrow, 
strong table, four or five feet in 
length, and covered with two 
or three thicknesses of a com- 
fortable or blanket, the lower 
portion of which should be 
covered with a piece of rubber 
or of oil-cloth, and over this 
a folded sheet, both of which 
should hang some distance 
down over the lower end of 
the table, so as to conduct the 
blood and other discharges into 
a bucket properly placed for 
their reception. One or two 
pillows should be provided on 
which to rest the head and 
shoulders of the patient, with- 
out raising them too much, so 
as to create a bend at the waist, 
and the arrangement of the 
table will be complete. 
Before the introduction of 
ansesthetics into surgery it was 
the invariable custom to fasten the hands and feet of the patient together by 
laces or bands. In America the limbs are secured by rollers, the initial ends 
being sewed into the form of loops, which are slipped over the wrists; after 
which the patient is made to grasp his feet in such a manner that, while the 
fingers rest across the soles, the thumbs are applied to the instep, and then 
the two are bound together by figure-of-eight turns made with the rest of 
the roller. There are many surgeons who still adhere to this custom of bind- 
ing, notwithstanding the use of anaesthetics. For myself, I nevei' employ 
any restraint of the kind. 
The fore-part of the day is always to be preferred for the operation, as in 
the event of hemorrhage or other complications the surgeon will have the 
advantage of a satisfactory light in searching for vessels or rendering what- 
ever assistance may be demanded. The patient should take a very light 
breakfast on the morning of the operation, simply a cup of coffee or a glass 
of milk with an egg, in order that he may suffer as little as possible from 
the sickness which so often follows the use of the anaesthetic. The rectum 
should be examined, and if found to contain any faeces it will be necessary to 
secure their removal by an enema of a little soap and water, administered 
about two hours before the cutting. The safety of the bowel is very greatly 
enhanced by this precaution. The hair must also be shaven from the 
perineum. Before proceeding to the operation, the surgeon should never 
neglect to reassure himself of the existence of the calculus, by repeating the 
test of sounding; and if unsuccessful in detecting the stone at this time 
he will not be justifiable in cutting his patient, even though he may have 
previously recognized the physical signs of its presence. The sound is a 
steel instrument, and should have one of two curves (Fig. 1376), which are 
sufficient to meet almost every form of the bladder. Some go so far as to 
insist that the clink, or sound of contact between the stone and the entering 
instrument, must be demonstrated to at least one other person besides the 
operator before extraction is attempted. But, if the surgeon has a practical 
familiarity with the subject of lithotomy, I would not insist on any such 
prerequisite. The existence of the calculus being placed beyond all perad- 
venture, the patient must be brought well down, so that his breech will pro- 
Fig. 1395 
Dissection of the male perineum: 1, skin, superficial fascia; 2, 
middle perineal fascia; 3, middle perineal fascia turned off the 
transverse perineal muscle; 4, accelerator urinse; 5, transverse 
perineal muscle and artery ; 6, erector penis; 7, sphincter ani; 8, 
perineal centre; 9, iscbio-rectal fossa; 10, internal pudic artery 
and branches; 11, Cowper's gland resting on deep fascia or tri- 
angular'ligament; 12, artery of bulb. A, line of incision in 
lateral operation where it enters the membranous urethra. 668 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
ject over the lower end of the table. If the urine has been retained for an 
hour before the operation, there will be no necessity for injecting the bladder; 
if not, three or four ounces of lukewarm water or of thin flaxseed-tea may 
be injected into the bladder after etherization. In children, when no volun- 
tary effort is made to hold the water, the practice of tying a piece of tape 
around the penis to prevent the escape of the urine is sometimes adopted. 
It is better, however, in such cases, to inject the bladder after the anaesthetic 
has taken effect. Any considerable distention of the organ with fluid is en- 
tirely unnecessary. 
Instruments.-The staff (Fig. 1396) is constructed of steel, and is about 
Fig. 1396. 
ten inches in length, having a handle with a rough surface, in order that 
it may be the more fixedly held. The groove is placed in the middle of 
the instrument. It should have a somewhat triangular shape, and extend 
from the middle of the staff to near its vesical extremity, which is usually 
well rounded or blunt. The curve of the instrument is important. It 
should commence rather abruptly, and be prolonged forward, with a very 
slight inclination upward. Two knives should be on hand. Different oper- 
ators have their partialities in regard to shape. The one I employ is about 
six and a half inclies in length, the blade making three inches of the whole, 
and its extremity being rather broad than sharp-pointed. (Fig. 1397.) The 
Lithotomy staff. 
Fig. 1397. 
Knife. 
Fig. 1398. 
Blunt-pointed bistoury. 
edge must be keen. A blunt-pointed bistoury (Fig. 1398) will prove useful 
should it be required to enlarge the opening made in the prostate. 
Fig. 1399. 
Knives of other shapes, preferred by different operators, are shown in Fig. 
1399. For extracting the stone two pairs of forceps must be at hand, one for the 
adult, and a smaller one for children (Fig. 1400), both moderately curved in 
the blades. 
LATERAL LITHOTOMY. 
669 
Fig. 1400. 
Lithotomy forceps. 
A scoop (Fig. 1401) will be required to extract the fragments should a stone 
break down under the pressure of the forceps. 
Fig. 1401. 
Lithotomy scoop. 
A catheter (Fig. 1402) is necessary for the purpose of injecting some tepid 
water into the bladder previous to the operation, and another, a gum one, 
with a large calibre, for washing out the bladder after the operation. 
Fig. 1402. 
Catheter for injecting the bladder. 
The syringe used for injecting is the ordinary hard rubber one, holding 
Fig. 1403. 
Catheter with Davidson's syringe. 
four or five ounces, or an ordinary Davidson's syringe fitted to the end of the 
catheter (Fig. 1403). 670 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
An instrument (Fig. 1404) has been devised which, being hollow, aims 
to unite the sound and the catheter in one. It proposes to accomplish too 
much. 
Fig. 1404. 
Catheter sound. 
It occasionally happens that a stone is too large to be drawn through the 
opening in the prostate: under these circumstances it becomes necessary 
to break the concretion into pieces before it can be extracted. For this 
purpose a large forceps with a screw attached will be required. (Fig. 
1405.) 
Fig. 1405. 
Large forceps for breaking stone. 
To the above-mentioned instruments must be added a tenaculum, ligatures, 
and sponges. These instruments, previous to beginning the operation, must be 
arranged on a tray in the order in which they will be required, and placed 
at a convenient distance from the operator, and alongside of an assistant 
detailed for the special object of handing and receiving them as they may be 
required. 
The grooved staff is now to be introduced into the bladder, and if felt to 
touch the stone the sensation is reassuring, as it reveals the fact of the in- 
strument being really within the viscus. It is not impossible that the staff 
in passing along the urethra might enter a false passage and slip in between 
the bladder and the rectum, thus leading the surgeon into a mortifying 
and fatal error: so that too much care cannot be observed in having the pre- 
liminary steps of the operation properly settled. 
The staff is next intrusted to the hands of an assistant, who stands on the 
left side of the patient, and who, while steadying the instrument with one 
hand in the manner directed, holds the scrotum out of the way with the. 
other. 
The staff-holder plays a very important part in lithotomy. lie should obey 
instructions implicitly; otherwise it is in his power to lead the operator greatly 
astray and cause irreparable damage to the rectum. The surgeon, before he 
commits the staff to the holder, takes the handle of the instrument in his 
own hand, introduces a finger of the other hand into the rectum, and with 
the two adjusts the guide in the place and in the position in which he desires 
it to be unchangeably held till the bladdei' is properly opened, and which is 
that up against the arch of the pubes, and nearly vertical, with the handle 
inclined very slightly towards the right groin. It will also be noted, while 
thus adjusting the staff, whether any faeces have descended into the rectum: 
if so, the bowel should be cleared before proceeding to operate, so as to 
defend this part of the intestine against injury by the knife. The limbs of 
the patient are put in charge of two assistants, each of whom places a knee 
in the axilla and the clasped hands under the sole of the foot, and thus they 
are held apart and in a flexed position. LATERAL LITHOTOMY. 
67 
The surgeon now takes his place, either kneeling on one knee or sitting on 
a low stool, in front of the perineum (Fig. 1406), and, taking in at a glance 
the raphe, anus, and tu- 
berosity of the ischium, 
makes an incision on the 
left side of the perineum, 
beginning on the side of 
the raphe about one inch 
in front of the anus, and 
carrying it back to a 
point midway between 
the tuber ischium and the 
verge of the bowel. This 
cut should penetrate 
boldly into the tissues, 
unless the perineum is 
shallow, when it should 
be made with more re- 
serve. As soon as the 
first incision is made, 
the operator at once in- 
troduces the index fin- 
ger of his left hand into 
the bottom of the wound, 
with the double object 
of defending the rectum 
(which he at the same 
time presses backward 
out of the way of harm 
as the deeper parts are divided by successive touches of the scalpel) and 
of searching for the staff, on discovering which the point of the knife 
is to be thrust into the 
groove of the instru- 
ment along the finger- 
nail of the digit, resting 
on its inner edge. (Fig. 
1407.) 
The lodgment of the 
knife at this objective 
point having been safely 
effected, it is to be run 
a little distance up and 
down in the groove to 
render its position cer- 
tain, and then, with its 
blade slightly inclined 
towards the ischium, 
it is pushed steadily 
onward through the 
prostate into the neck 
of the bladder, the en- 
trance to which is usu- 
ally announced by a 
gush of fluid through the wound. 
An error which is often committed during this stage of the operation is 
that of holding the knife as it glides along the groove towards the bladder too 
nearly parallel with the groove of the staff, thus making too small a wound in 
the prostate, instead of keeping it at first at a considerable angle and bring- 
ing it gradually to the parallel position towards the completion of the cut, in 
Fig. 1406. 
Position of patient, operator, and assistants in the operation of lateral 
lithotomy. 
Fig. 1407. 
Directing the knife into the groove of the staff. 672 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
which case the opening in the prostate will be amply large for the extraction. 
After the division of the vesical neck, the knife is to be withdrawn and the 
finger at the bottom of the 
wound carried along the staff 
into the bladder until its ex- 
tremity comes in contact with 
the stone, when the staff must 
be removed and the forceps con- 
ducted along the finger into the 
organ. (Fig. 1408.) 
It was at one time the prac- 
tice both in England and in 
America to incise the prostate 
with the gorget. (Fig. 1409.) 
This was accomplished in the 
following manner. Aftei' opening 
the membranous portion of the 
urethra, the beak of the instru- 
ment was introduced into the groove of the staff, previously laid bare, and, 
after running it up and down to make sure of its position, the surgeon 
Fig. 1408. 
Forceps introduced and turned concavity upward previous to 
grasping the stone. 
Fig. 1409. 
Physick's gorget. 
depressed the handle of the staff with his left hand, while with the right 
the gorget was pushed onward through the prostate body. Formerly, in the 
United States, this instrument was popular with Physick, Gibson, Barton, 
McDowell, Dudley, and others; but at present there are few surgeons who 
think of employing it. The knife, in point of dispatch, certainty, and security, 
is in every way preferable. 
After the forceps have entered the bladder the finger must be withdrawn, 
and the blades of the instrument separated and closed over the calculus. In 
introducing the forceps into the bladder the convexity of the blades should 
be kept anteriorly, but after entering the organ the instrument is to be 
turned so as to bring the same surface posteriorly. In grasping the stone, 
it should be the aim of the surgeon to seize it by its smallest diameter, 
which can be determined only by the degree of separation in the blades of 
the instrument as the calculus is released and again caught. 
The late Professor N. R. Smith, of Baltimore, used in the operation for stone 
an apparatus consisting of a catheter, a staff, and a lithotome all in one instru- 
ment. (Fig. 1410.) The catheter in its shape, being nearly rectangular, resem- 
bles the Buchanan staff. To the shank or handle of the catheter is hinged an 
incisor, which when pressed home enters a slot at the angle of the staff. This 
slot or groove as it runs forward towards the vesical extremity of the instrument 
winds round towards the left side. In the slot there is also a cup attached to 
a piece of spring-steel, which occupies the canal of the long arm of the instru- 
ment. In employing the apparatus in a case of stone the incisor is drawn 
back and the catheter introduced into the bladder; its angle can then readily 
be recognized in the perineum. While the staff is now firmly held in posi- 
tion, the incisor is pressed into the perineal tissues until its point enters the 
slot in the catheter, when it must be withdrawn and the lithotome con- 
ducted through the wound until its point enters the cup: it is then to 
be pushed onward into the bladder, the knob approaching the end of the LATERAL LITHOTOMY. 
673 
handle as the knife advances, a fact which shows that the lithotome is 
properly and securely following the groove on the staff. 
Fig. 1410. 
Professor N. K. Smith's lithotomy instrument. 
Extraction.-In bringing the stone through the incision in the neck of the 
bladder it must be coaxed out by a gentle lever-movement of the forceps, 
conjoined with traction, during which counter-pressure by a finger applied 
to the lower edge of the wound in the prostate, thus slipping the lattei' 
over the surface of the calculus, will materially aid in the procedure. The 
line of traction should be backward towards the more ample outlets of the 
pelvis. 
Some surgeons advocate stretching the prostate to any extent which may 
be required for the passage of the stone. A better term than, stretching, 
perhaps, would be laceration, for this is much more likely to take place 
than stretching. It is better to make a free and clean section of the pros- 
tate, so that the calculus can be extracted without either tearing or bruising 
this body. The dilatability of the sphincter vesicae which surrounds the 
neck of the bladder is very great, and it should not be cut. The evils of 
an opposite course are more likely to follow lithotomy in the adult than in 
the child, as in the latter the prostate is in a comparatively undeveloped 
state. In no instance, however, should the incision extend beyond the lateral 
lobe of the prostate. It is better, indeed, that it should not extend entirely 
through the lobe, as when it exceeds the limits of this body it will trench on 
the neck of the bladder and the recto-vesical fascia, and necessarily expose 
the patient to the danger of urinary infiltration and peritonitis. 
In cases of deep perineum or of enlarged prostate, the finger of the oper- 
ator may be too short to reach the bladder, even after the prostate has been 
sufficiently incised. Under such circumstances the edge of the closed blades 
of the forceps can be applied to the groove of the staff, and be thus con- 
ducted into the cavity of the organ, or the beak of the blunt gorget may be 
inserted into the groove and carried forward into the bladder. This done, 
the staff must be withdrawn and the forceps entered along the concavity 
of the gorget. As soon as the forceps are found to move freely in the bladder, 
the gorget has fulfilled its office, and must be withdrawn. 
After the extraction of the stone it is the duty of the surgeon to explore 
the bladder, either with the finger or with a sound, to ascertain if another 
stone is present. 
Encysted stone can be best dealt with by the finger inserted through the 
wound into the bladder, when it can be used both to lacerate the cyst wall 
and to detach the calculus. 
Washing the bladder.-On the removal of a stone from the bladder, it is 
quite common for some scale or fragments to be ground off by the forceps 
before the concretion is delivered, or the calculus may crumble into pieces 
under the pressure of the extracting forceps. To make sure that no particle 
is allowed to remain and thus form the nucleus for another concretion, the 
VOL. II.-43 674 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
bladder must be washed out by a stream of tepid water thrown into the 
organ through a gum catheter introduced by the wound: the reflex current 
will carry with it whatever debris may have remained. 
Lithotomy in Children does not differ materially from that in the adult; but 
there are a few anatomical peculiarities belonging to very young people 
which must not be overlooked, as they have an important bearing on the 
operation. These are, first, the less ample outlet of the pelvis, which necessi- 
tates more restricted incisions than would be allowable in grown persons; 
secondly, the smallness of the membranous urethra and the undeveloped 
state of the prostate body, on account of which the knife must be used with 
precision, opening this part of the canal in the proper direction and con- 
tinuing the incision deliberately onward into the prostate. If there is any 
indecision at this stage of the procedure, or any hacking with the point of 
the knife, the membranous urethra may be completely detached from the 
prostate, or so nearly severed that it is torn off by the force used to carry 
the finger into the bladder, when the latter will be likely to recede before the 
pressure and slip away from the staff, and from the digit also, thus completely 
foiling the surgeon in his search for the stone. Thirdly, the loose cellular 
tissue which forms the recto-vesical fascia allows the bladder and rectum to 
separate very readily, forming a cavity into which the finger slips without 
resistance, imparting the false impression of being within the bladder. This 
has often happened even in the hands of excellent surgeons. It is better, 
therefore, to make a free cut through the prostate, so as to admit the finger 
without much opposition, and also to remember the button-hole grip of the 
sides of the wound in the prostate, which is felt ■when the digit is properly 
introduced. 
Causes which may delay the extraction.-Though it is not very common at 
the present day to encounter very large stones in the bladder, occasion- 
ally one will be met with which, in consequence of its magnitude, cannot be 
extracted through the usual incision in the prostate. In such an event either 
the opening in the latter body must be enlarged, or the calculus must be 
broken. If the size is not too great, the former plan should be adopted ; and 
the cut should be made by a blunt-pointed bistoury, though at the same 
time too free incisions of the prostate are to be deprecated, as the knife may 
very easily go beyond the limits of this body and open the pelvic fascia, thus 
exposing the patient to the dangers of urinary infiltration. To obviate this, 
the right lobe of the prostate may be divided obliquely outward and down- 
ward, the two incisions through the lateral portions of the gland forming a 
triangular flap, which, when depressed, leaves a similarly-shaped opening into 
the bladder, which will allow of the passage of a very large calculus. It is 
safer, however, when the calculus cannot be drawn through the usual incision 
at the neck of the bladder, to introduce the large crushing forceps and break 
the stone, removing the pieces by the ordinary forceps. In judging of the 
fitness of a stone to be extracted, the surgeon must not be led astray by a 
false impression as to its size. He must be certain that it has been grasped 
by its smallest diameter. The distance between the blades of the forceps 
when a calculus is seized in one direction will often be greatly lessened when 
it is caught in another diameter. 
Position of the stone.-It may happen that the inferior fundus of the bladder 
lies so deep that difficulty will be experienced in bringing the blades of the 
forceps into contact with the calculus. This embarrassment can be overcome 
by inserting a finger into the rectum and raising the depressed part of the 
bladder, so as to bring the concretion into a more favorable position for 
extraction (Fig. 1411); or forceps having a more pronounced curve in the 
blades can be substituted for those in common use. If these fail, the scoop 
may be used. 
Again, the stone may be lodged behind the pubes in a sacculated pro- 
longation of the anterior wall of the bladder. Of course it would, in such a LATERAL LITHOTOMY. 
675 
location, be wholly inaccessible to the extracting forceps, and would require 
for its dislodgment and removal pressure with the fingers above the pubes, 
with or without the assistance of an 
abruptly-curved scoop. When the 
calculus is lodged in a pouch or sac 
formed in the walls of the bladder, 
the scoop will again be called into 
requisition for its extraction; and 
when encapsulated, as occurred in 
my own practice in one instance, 
the investing wall will require to be 
lacerated, and the concretion shelled 
out with the finger. 
Vicious formation of the pelvis, such 
as occurs in children who have suf- 
fered from rickets, is another cause 
rendering the removal of a calculus 
a matter of difficulty. In this condition the obstacle may consist either in 
the close approximation of the rami of the pubes and ischium, or in an ex- 
treme contraction in the antero-posterior diameter of the pelvis. The remedy 
will consist either in breaking up the stone or in opening the bladder above 
the pubes. 
Several calculi.-When a number of stones exist at the same time in the 
bladder, they are to be removed by the repeated introduction of the forceps ; 
and this may prove a cause of delay. 
Peculiarities in the shape of a stone will sometimes render its extraction a 
matter of delay and difficulty, as when there projects from its surface a long 
spike or process which, when an attempt is made to pull it through, catches 
on the side of the opening in the prostate. Or an irregularity of this nature 
may prevent the proper application of the forceps to the stone. A finger in- 
serted into the bladder, so as to admit of an examination of the concretion, 
will reveal any irregularity of the kind alluded to, and the remedy will 
consist in crushing off the process by the forceps or the lithotrite and re- 
moving the parts separately. 
Diminutive stones.-A calculus may be so small that when the bladder is 
opened the concretion will be carried through the opening by the force of 
the current of water which gushes out, and either become fixed in some part 
of the external wound or fall into the vessel placed at the foot of the table 
for receiving the blood and other discharges, thus subjecting the surgeon to 
the mortification of delay in a further search of the bladder. In one instance 
I saw a small stone projected with such force from the bladder that it was 
buried in the cellular tissue at the base of the scrotum and was not discovered 
until it had created an abscess by its pressure. In another instance which 
I recall, the surgeon was about to conclude that he had committed an error 
in diagnosis, not finding the calculus in the bladder, after lithotomy had been 
performed, when, on searching the bucket beneath the table, the concretion 
was discovered. 
Vesical incrustation.-A phosphatic incrustation of the inner surface of the 
bladder is sometimes seen to exist along with a free calculus, and must neces- 
sarily retard the work of clearing out the debris. I have seen several ounces 
of calcareous matter adherent to the mucous surface of the bladder after 
an operation for stone. This material is most satisfactorily detached by the 
scoop, sometimes by the finger, and demands the free injection of tepid water 
into the organ in order to wash out all the fragments. 
Tumors of the prostate may offer an obstacle to the finger reaching the 
bladder, in which event the procedure adopted in a case of a very deep peri- 
neum must be practiced, namely, that of sliding the forceps into the organ 
along the groove in the staff. 
After-Treatment.-After the removal of the stone and the control of 
Ftg. 1411. 
Stone in the inferior fundus of the bladder.  INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
676 
any bleeding which may continue, the patient should be placed in the bed, 
which must be properly prepared for his reception. For this purpose a hard 
mattress, covered with a piece of gum-cloth, and over this a sheet, answers 
best. In order that the patient and his bed may be kept dry, a draw-sheet 
rolled up on one side and placed across the bed, under the hips, will be re- 
quired. This, as often as it becomes wet with the urine, must be drawn from 
beneath the buttocks and the soiled portion rolled up, the sheet being replaced 
by another as soon as the clean rolls become exhausted. I sometimes find it 
advantageous to press beneath the nates a large sponge, two-thirds of which 
(the portion resting on the bed) is inclosed in an oiled-silk bag. When the 
sponge becomes soaked with the urine, it can be removed from the bag and a 
clean one placed in its stead. To prevent excoriation of the soft parts from 
the contact of the urine, the hips should twice a day be smeared over with 
benzoated oxide of zinc ointment. The position which is most comfortable 
to the patient is on the back • although I never object to his turning on 
the side if that is preferred. There is no necessity either for tying the 
knees together or for introducing a catheter through the wound into the 
bladder. For the first two days the wTater usually escapes freely through the 
cut. After this, for two or three days it will probably flow also through the 
urethra, in consequence of the inflammatory swelling succeeding the operation 
temporarily closing the prostate. With the subsidence of this the wound 
in the prostate body again begins to gape, and the urine resumes the original 
course through the incision, and so continues to flow until the latter is grad- 
ually closed by granulation. It then follows the natural channel through the 
urethra. 
The time required for healing the perineal incision varies from three to 
six weeks. In several instances union by first intention has been observed. 
Crichton, in an aggregate of 200 operations, witnessed this mode of healing 
twenty-three times,-an experience which I imagine is quite exceptional. 
In children I have seen the cut close as early as the fourteenth day. It is 
a good rule not to allow the patient to sit up until the w'ound has healed, 
as otherwise a fistula may follow. 
After the patient has been placed in bed, an opiate ought to be adminis- 
tered, to be repeated as often as may be necessary to relieve pain. The 
bowels must be kept in a quiet state for at least four days, after which they 
are to be opened by a laxative of oil or Rochelle salt. The diet for the first 
few days should be light and unstimulating, as milk, after which a more liberal 
allowance can be prescribed, consisting, in addition to the milk, of broth and 
eggs. By the beginning of the second week solid and more substantial ar- 
ticles of food will be admissible. 
Accidents during Lithotomy.-The first I shall mention is hemorrhage. 
There is always some hemorrhage in every operation of lithotomy. The 
source of the bleeding is the transverse perineal artery, which is necessarily 
divided when the knife severs the transverse perineal muscle. In most cases 
the vessel will not require a ligature, as the flow of blood ceases sponta- 
neously. If this should not be the case, however, the vessel must be drawn 
out with a tenaculum and tied. In some instances, in consequence of a long- 
continued vesical irritation, this artery becomes greatly enlarged, and will 
give rise to a very profuse hemorrhage : in such an event the surgeon 
should tie the vessel before proceeding further with his operation. 
Independently of the transverse perineal, the vessels which are prone to give 
trouble are the artery of the bulb, the internal pudic, those of the bulbous 
portion of the corpus spongiosum, the prostatic plexus of veins, and the inferior 
hemorrhoidal arteries. The resources for stopping undue bleeding at the com- 
mand of the surgeon are cold, heat, the ligature, the forceps, and compression. 
Cold.-Cold may be applied by the introduction into the wTound of lumps 
of ice, or of lint soaked in cold water; or a stream of cold water may be 
thrown in by a syringe. 
Heat.-When cold fails to effect the desired end, heat will sometimes sue- LATERAL LITHOTOMY. 
677 
ceed, and may be applied by thrusting deeply into the wound a pledget of 
lint previously saturated with boiling hot water, and allowing it to remain 
for a few moments. The temperature, to prove effectual, must be such as 
can be barely borne by the hands of the surgeon. 
Ligature.-The application of a thread to the transverse perineal artery 
or to an opening in the bulb is not a task of any great difficulty, as either is 
quite accessible to the tenaculum or the forceps. But when the arteria 
bulbosa, or the internal pudic, from which the former is derived, is injured, 
not only will the bleeding be copious and dangerous, but ligation will be very 
difficult. In dealing with the first-named vessel it may be necessary to en- 
large the wound in an upward direction, so as to render it more accessible : 
it is preferable, however, to watch the point from which the blood issues, the 
sides of the wound being held asunder and in a good light, and to include the 
point, along with some portions of the surrounding tissues, in the grasp of the 
blades of a pair of dressing forceps, which can be locked together and allowed 
to remain for thirty-six hours in the wound, as practiced by Professor Gross. 
When the internal pudic artery has suffered (an accident which can occur 
only by lateralizing too much the edge of the knife), the ligature becomes 
imperative. This vessel is large, and is sheltered under a strong fascia by 
the inner edge of the ramus of the ischium. It is accompanied by a vein 
and by the internal pudic nerve. Thrice have I been called to ligate this 
vessel. The instrument usually depicted a< that particularly suited for 
this operation, and commonly known as Physick's forceps and needle 
(Fig. 1412), is not at all adapted to this purpose, nor is there any evi- 
Fig. 1412. 
Physick's forceps and needle. 
dence that it was ever used in tying the vessel by the distinguished surgeon 
whose name it bears. The only instrument well adapted to this ligation 
is Horner's awl. (Fig. 1413.) This consists of a strong curved awl-shaped 
Fig. 1413. 
needle, having a shoulder near its extremity, and mounted on a stout handle. 
A thread is first looped over the shoulder of the instrument, after which the 
point of the needle is passed along the inner side of the ramus of the ischium, 
half an inch in front of the tuber, and made to emerge on the hither side of 
the vessel, the point of the needle being at the same time directed sufficiently 
towards the surface to enable the surgeon to disengage the loop of the liga- 
ture from its shoulder, wThen the instrument is to be withdrawn and the 
thread tied. The ligature of the internal pudic would command also the 
circulation through the artery of the bulb. 
Pressure.-Pressure can be employed either through the wound or through 
the rectum. When made in the wound, it can be done by a catheter and 
strips of lint, by the chemise, or by the air tampon. 
When the first plan is resorted to, a gum catheter of good size is con- 
ducted, by the finger through the wound a short distance into the bladder, 
Horner's awl. after which one end of a long strip of patent lint is carried down on the 
point of a director to the bottom of the wound, and the remaining portion 
pushed in by installments until the whole piece is firmly packed in around 
the catheter. 
The chemise is made by making an opening in the centre of a square of 
muslin, passing through this a gum catheter, and securing the two together 
about two inches and a half from the end of the tube by a thread. (Fig. 1414.) 
The end of the catheter is 
passed into the bladder as far 
as the chemise, and the latter 
packed with one or more strips 
of lint or linen. 
Whether the catheter and 
lint, or the chemise, is used, 
neither should be permitted 
to remain longer than twenty- 
four, or, at furthest, thirty-six 
hours. In their removal the 
proper mode of proceeding is to seize the free end of the strip used in the 
packing, and slowly withdraw it without the least rudeness. The advan- 
tage of having the packing to consist of a single piece will be apparent when 
the time for its withdrawal has arrived, as it does not necessitate the in- 
troduction of the dressing forceps into the wound. 
The air tampon, the device of Mr. Buckstone, constitutes a very effective 
arrangement for the distribution of pressure. This contrivance is made by 
securing to a stout rubber catheter or tube a gum bag; the ends of the 
former should project some distance beyond the latter. To the elastic bag 
is fitted a rubber tube with a stop cock at its free end. The vesical end of 
the tube is carried into the bladder, and, after being thus placed in posi- 
tion, the elastic bag is inflated through the gum tube, the distention of the 
former acting on all the inequalities of surface of the wound and effectually 
controlling the bleeding. As 
with the catheter and lint, or 
with the chemise, twenty-four 
or thirty-six hours will be 
quite long enough to maintain 
the pressure, which can be 
gradually moderated by al- 
lowing a little air from time 
to time to escape through the 
stop-cock. (Fig. 1415.) 
Pressure through the rec- 
tum was first practiced by Dr. 
Kerr, surgeon to the hospital 
at Canton, China. It is also 
a potent means of arresting 
hemorrhage. This can be 
satisfactorily demonstrated by 
inserting a finger into the 
rectum in a case of obstinate bleeding after lithotomy, and pressing the 
anterior wall of the bladder firmly towards the pubes, when the flow will 
immediately stop. Dr. Kerr's plan was to substitute the pressure of the 
finger by packing the bowel with old linen or lint. 
The practice of soaking lint or bits of sponge with styptics, as the salts of 
iron, and pushing them into the deep parts of the wound, is to be deprecated, 
leaving as it does a dirty incrustation adherent to the tissues. Indeed, all 
methods of applying pressure to a lithotomy wound are to be regarded as 
complicating the case, though they are often the better choice of two evils. 
Failure to enter the bladder.-This has frequently occurred, and is more likely 
678 
INJURIES AND DISEASES OF THE GENIT0-UR1NARY ORGANS. 
Fig. 1414. 
Chemise. 
Fig. 1415. 
Buckstone's tampon. LATERAL LITHOTOMY. 
679 
to attend the operation in children than in adults, in consequence of the 
greater mobility of the bladder and the rectum, and the loose connection 
between them. The error arises from the opening into the urethra not being 
made sufficiently free, so that the finger, and sometimes the forceps, glides 
into the recto-vesical fascia. It is an unfortunate mistake, and is liable to be 
followed by urinary infiltration, pelvic cellulitis, peritonitis, and death. An 
accident of this nature can be easily avoided by remembering that when the 
finger is in the proper route to the bladder it will feel the button-hole grip of 
the sides of the prostate, very different indeed from the sensation produced 
by contact with the loose, unresisting walls of the recto-vesical space. There 
will also be felt, when the finger is on the right way to the bladder, the bare 
staff and the surface of the stone. Should an accident of this kind befall an 
operator, it will be imperative, after the mistake has been corrected and the 
calculus removed, to keep, during the first week, a catheter in the bladder, 
passed through the wound, in order to conduct away the urine and prevent 
its extravasation into the cellular tissue of the pelvis. 
Opening the bladder beyond the prostate.-This may be done by continuing 
the incision through the prostate and onward into the neck of the organ, 
or the urethra may be missed altogether and the organ penetrated posterior 
to the prostate body. The sequences of so grave a miscalculation are the 
same as those which follow opening up the recto-vesical space. They are 
likely to prove fatal. 
Wound of the rectum.-This accident has often happened. It is sometimes 
the fault of the staff-holder, who fails to keep the instrument well up under 
the arch of the pubes, and thus allows the prostate and the rectum to be in too 
close contact, so that the bowel is cut as the knife is pushed onward along the 
groove of the staff. Or the fault may lie wholly with the operator, who either 
fails to press the intestine sufficiently aside with the left index finger when 
the deeper incisions are being made, or does not at this stage of the operation 
lateralize his bistoury to the proper extent. The accident would also be 
favored by the bowel being distended with faeces at the time of the operation. 
I have known the rectum torn during the forcible efforts made to extract a 
large, rough stone. The higher the wound in the bowel, the less probability 
is there of the patient deriving any benefit from treatment. A recto-vesical 
fistula will follow, with all the evils resulting from the passage of the urine 
into the rectum, and of the contents of the latter into the bladder. When 
the opening happens immediately above the sphincter, the case is much more 
promising: there is a probability of its closing up as the granulations approach 
the surface. Should this not follow, the proper treatment will be, after the 
wound in the perineum has healed up, in an ordinary anal or rectal fistula, 
to lay open the bowel and the -wound into one, and to extend the incision 
through the sphincter to the surface of the perineum. When the opening is 
high up and very small, the actual cautery is worth a trial. In one case I 
have seen it succeed; but the hot iron must be withheld until the opening has 
contracted to its smallest dimensions, which will require several months. 
These recto-vesical fistulse predispose the patient to another attack of stone, 
in consequence of foreign substances entering the bladder from the rectum 
and supplying a nucleus for the deposition of the urinary salts. 
Accidents following Lithotomy. 1st. Retention of urine.-The opening 
in the prostate may be made so small that when the inflammatory swelling 
which succeeds the operation sets in, there may not be sufficient space for 
the escape of the urine; or, as in a case which I recently witnessed, the re- 
tention may be occasioned by a fibroma at the neck of the bladder, which, 
after the removal of the stone, will project both into the wound in the pros- 
tate and into the urethra. The cessation in the escape of urine through 
the incision, the distention of the bladder, which can be felt above the pubes, 
and the pain and fruitless efforts to urinate, will sufficiently indicate what has 
happened. The remedy is catheterization through the urethra, which will 
require to be repeated until the urine resumes its course through the cut. 680 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
2d. Pelvic cellulitis (by which is meant diffuse inflammation of the connect- 
ive tissue about the prostate body, the vesicular seminales, the bladder, and 
the fascia connecting the bladder and rectum as high as the reflection of 
the peritoneum) may arise from various causes. The most commoh are the 
extravasation of urine-due either to prolonging the incision beyond the 
limits of the prostate body, or to disturbing the recto-vesical fascia by the 
finger or forceps, thus destroying the natural barrier to the upward intrusion 
of the urine-and the rough, forcible extraction of large stones, thus damaging 
the prostate. A case of pelvic cellulitis may originate in a phlebitis of the 
prostate veins, which becomes at length propagated to the connective tissue, 
or in disease of the kidneys. A general vitiated state of the health is no in- 
considerable factor in the production of this condition. It appears generally 
before the third day, and is announced by rigors, high febrile excitement, 
sweating, hiccough, a dirty, sallow complexion, and great prostration, ac- 
companied by passive delirium. The inflammation is followed by suppuration 
and gangrene of the cellulai' tissue of the pelvis, peritonitis often destroying 
the patient by septicsemic or pysemic poisoning. 
The treatment must be based on general principles, giving exit to any 
accessible purulent accumulation by incisions, disinfecting the parts by injec- 
tions of a solution of permanganate of potash, sustaining the strength with 
concentrated nourishment, stimulants, and tonics of quinine and iron, and 
relieving pain and restlessness by opiates. 
Diphtheritic deposition.-In seasons when diphtheria is prevailing, the wound 
of a lithotomy patient is liable to become covered with the peculiar exudation. 
This may occur quite independently of constitutional symptoms; though the 
contrary is oftener the case. 
Local applications, other than those which are required from motives of 
cleanliness, do no good in cases of this nature. The surgeon must rely on 
general treatment, as the free use of chlorate of potash, iron, and capsicum, 
with milk, beef-tea, brandy, and wine. 
Sloughing.-When the tissues have been extensively bruised in extracting 
a calculus (particularly in a person whose system has been broken down by 
intemperance and other excesses), or where in consequence of some compli- 
cation the frequent introduction of the forceps has been necessary, the 
vitality of the parts may be so seriously impaired as to induce mortification. 
From causes of this kind I have seen extensive sloughing take place, in one 
instance laying open the rectum. 
In cases of this character, in addition to frequent ablutions with disinfect- 
ing solutions and the prompt removal of any detached shreds of disorganized 
tissue, the patient will require tonics, stimulants, opiates, and a supporting diet. 
Inflammation of the prostate.-It is a matter of surprise that this body does 
not share in the evil effects of operation for stone more frequently than obser- 
vation proves to be the case. What with the violent stretching, lacerations, 
multiple nicks with the knife, and bruisings while the calculus is being drawn 
through, it is certainly subjected to much traumatic violence. Unless when 
a partially detached portion of the prostate is found hanging loose (when it 
should be clipped off), or when a fibroma imbedded in its substance has been 
in some measure enucleated (in which case its removal will be demanded), the 
correction of the injury may be safely left to the natural process of repair. 
Cystitis.-There is always present in cases of stone some degree of cystitis. 
This is not unfrequently increased for a short time through the effects of the 
wound inflicted in lithotomy. It is, however, exceedingly uncommon to find 
the inflammation of the bladder continue long after the extraction of the 
calculus, except in old cases of stone. The foreign body once removed, the 
cystitis soon subsides. 
Hemorrhage into the bladder.-Blood sometimes, instead of escaping exter- 
nally, finds its way into the bladder, and the viscus may become greatly dis- 
tended with clots, giving rise to much straining and vesical distress. When 
the patient is unable to expel the coagula, a catheter should be introduced LATERAL LITHOTOMY. 
681 
into the bladder through the urethra and the clots broken up, so as to favor 
their escape through the wound. 
Suppression of urine following operation for stone is always an alarming 
circumstance. Though generally associated with disease of the kidneys, it 
may nevertheless occur in a healthy state of these organs. In either con- 
dition it is an evidence of the nervous system having sustained a profound 
shock, and is announced by rigors, sweating, headache, thirst, vomiting, and 
pain in the lumbar region, followed by delirium, stupor, absence of urine, 
coma, and death, the fatal result sometimes occurring in thirty-six or forty- 
eight hours. 
The treatment consists in applying over the loins hot poultices containing 
leaves of digitalis, and the internal use of diuretics, as acetate of potash or 
infusion of digitalis. If stimulants are demanded to counteract the pros- 
tration, Holland gin will be the most efficacious. 
Incontinence of urine is occasionally witnessed after lithotomy, particularly 
in young subjects, and may be due either to injury sustained by the sphincter 
vesicse, or to the over-stretching of the prostate during the delivery of the 
stone. This incontinence is much more annoying during the day than during 
the night, the recumbent position being apparently favorable to the retention 
of the urine. The disability usually passes away as the work of repair ad- 
vances, though it may prove to be permanent. The remedies employed in 
such cases, as iron, strychnine, cantharides, etc., are of little or no use. 
Orchitis.-Inflammation of the epididymis or of the testes, when present, 
may either be the effect of injury to the prostate, or may result from some 
irritation affecting the urinary passages and altogether independent of the 
operation. When it comes on in twelve or fourteen days after the cutting, 
the latter is generally the case. The treatment will not differ from that 
proper to orchitis arising from other causes. 
Peritonitis after lithotomy, though not common, may occur when the 
recto-vesical fascia has been much disturbed. It may also originate from the 
bruising of the prostate, or from counter-puncture of the walls of the bladder,- 
an accident which arises from keeping the point of the knife in too horizontal 
a direction, and in carrying it backward too far when the viscus is empty and 
collapsed. Tympanitis, abdominal tenderness, a quick, corded pulse, flexed 
limbs, and constipation reveal the inflammation of the peritoneum, which must 
be met by leeching, and subsequently by blistering the abdomen, also by the 
use of hot poultices, and of opium in sufficient quantities to allay pain and 
restlessness. 
Pyaemia is one of the sequences of lithotomy. It generally occurs in pa- 
tients of intemperate habits, or in those whose health has been seriously 
impaired by previous disease. It is ushered in by a sharp rigor, high tem- 
perature, a frequent pulse, sweating, prostration, and probably an icterode 
state of the face and conjunctiva?. 
The treatment must be a sustaining one throughout, embracing tonics of 
quinine and iron, stimulants, and liquid nourishment. 
Sexual defects.-It is not often that any complaint is heard from persons 
cut for calculi as to the operation having affected their potency in the sexual 
act. When sterility or impotence does occur as a sequel of lithotomy, it must 
be referred to some injury of the seminal ducts, to inflammatory changes in 
the prostate, or to a fistula, into which the spermatic secretion is discharged 
during ejaculation. There is no remedy likely to remove the difficulty. 
Fistula.-The perineal wound may fail to heal entirely, leaving a fistulous 
tract, which in some instances is so small as scarcely to admit the smallest 
probe, and through which only a very small amount of water passes during 
urination. The opening will often close up without any application, even 
though the patient is allowed to go about. Should this not be the case, the 
opening will require to be stimulated by passing along the tract once or twice 
a week a silver probe dipped in nitric acid. Passing the water on the hands 
and knees, or when lying on the right side, to divert the urine (as is supposed) 682 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
from the opening, is a useless precaution. The defect is not in the bladder, 
but in the prostatic urethra: therefore posture cannot affect the stream of 
water in this part of the channel. A more valuable device is the application 
of pressure against the prostate when urinating, by a finger inserted into the 
1'ectum, or, what is next best, on the perineum, immediately in front of the 
anus. If these measures fail, the water must be drawn at stated intervals 
with the catheter for eight or ten days, so that the fistula may be protected 
from the contact of the urine. As a last resort, it may become necessary to 
enlarge the fistulous tract with the knife, down to the prostate, thus vivifying 
its edges and favoring their union-, following the operation with the use of the 
catheter until the consolidation is completed. 
Phosphatic incrustation.-In certain states of the urine the edges of a lith- 
otomy wound become incrusted with phosphates, which necessarily retard the 
healing. These are best removed by a wash of nitric or muriatic acid,-three 
or four drops of the acid to the ounce of water. The internal use of dilute 
nitric acid will also contribute to the correction of the evil. 
Mortality.-The circumstances which affect the mortality in lithotomy are 
age, disease of the urinary organs, the size of the calculus, and the general 
health of the patient. The individual skill of operators, doubtless, must not 
be ignored in the enumeration of results obtained from this operation. In 
5149 cases of lateral lithotomy performed in twenty-one hospitals and tabulated 
by Gross, there were 4461 recoveries and 688 deaths, a mortality of 15.42 
per cent. Cheselden, who took the initiative in popularizing the lateral opera- 
tion for stone, lost 20 cases in 213 operations, or 9.38 per cent. 
Since 1875 there have been reported in various medical journals, domestic 
and foreign, 1192 cases of lateral lithotomy, with 106 deaths, or 8.89 per cent. 
Adding these cases to 10,150 collected by Gross from the tables of various 
operators from Cheselden down, we have 11,342 cases of lateral lithotomy, 
with 1220 deaths, a mortality of 10.75 per cent. 
Age constitutes a potent factoi' in the mortality of lithotomy. The tables 
of Coulson, which embrace 2972 cases, exhibit a death-rate of 1 in 13 cases 
of patients under ten years of age; from ten to twenty, 1 in 9 ; from twenty 
to thirty, 1 in 6; from thirty to forty, 1 in 5; from forty to fifty, 1 in 4; 
from fifty to sixty, 1 in 3.65; from sixty to seventy, 1 in 3.23; from seventy 
to eighty, 1 in 2.71. The average for all ages in Coulson's cases is 1 in 9, or 
11.11 per cent. 
Sir Henry Thompson, in an analysis of 1827 cases collected from the hos- 
pitals of Great Britain, estimates the death-rate at 1 in 17| for patients under 
eleven years of age; between twelve and sixteen, 1 in ; from seventeen to 
twenty-nine, 1 in 7J; from thirty to forty-eight, 1 in 7j; from forty-nine to 
seventy, 1 in 4J; from seventy-one to eighty-one, 1 in 31; the average mor- 
tality of the whole being 1 in 8. 
Of 217 cases collected for me by Dr. Baum, 50 were under five years of 
age, of which number 49 were cured and 1 died. The average age of these 
50 cases was 31 years. Of 54 cases between five and ten years of age, 53 
recovered and 1 died; the average age being 61 years. Of 27 cases ranging 
from ten to twenty years, 26 were cured and 1 died ; the average age being 
13 i years. In 11 cases ranging from twenty to thirty years, there were 
9 cures and 2 deaths, or 1 in 5J ; from thirty to forty, 5 cases, with 1 death; 
from forty to fifty, 9 cases, with 8 cures and 1 death; from fifty to sixty, 18 
cases, with 13 cures and 5 deaths, or 1 in 34; from sixty to seventy, 28 
cases, with 21 cures and 7 deaths, or 1 in 4; from seventy to eighty, 13 cases, 
with 11 cures and 2 deaths, or 1 in 61; over eighty, 2 cases, with 2 cures. 
Dividing these 217 cases into two groups, it will be seen that 131 were under 
twenty years of age, only 3 of whom died, while of 86 ranging in age from 
twenty to eighty, 18 died; the mortality for the whole number, 21, being 
9.67 per cent. 
Size and weight of calculus.-The bulk and density of calculi also exert a 
material influence on the results of lithotomy. This fact has been well LATERAL LITHOTOMY. 
683 
brought out in the tables of both Crosse and Garden. In the former, of 704 
cases of lithotomy performed in the Norwich Hospital, it was found that 
the mortality when the stone did not exceed one ounce was 1 in 11 cases; 
when not exceeding two ounces, 1 in 61 cases; from two to three ounces, 1 
in 218 cases; from three to four ounces, 1 in 157 cases; and from four to five 
ounces, 1 in 166 eases. The tables of Dr. Garden, the data of which were 
drawn from the Saharunpore Hospital (and which embrace 625 cases having 
a bearing on the subject under consideration), furnish substantially the same 
results. The deaths following the extraction of these large calculi are for 
the most part due to pelvic cellulitis, the result of laceration of the prostate, 
and of urinary infiltration. 
Disease of the kidneys.-A patient suffering from disease of the kidneys 
is a dangerous subject for lithotomy, and nothing but the direst necessity 
should induce a surgeon to attempt any cutting operation for stone. Such 
persons should be relegated, in most instances, to the domain of lithotrity. 
General bad health, proceeding from cardiac or hepatic disease, from diar- 
rhoea, from intemperance, or from any cause seriously affecting the nutrition 
of the body, will materially lessen the prospects of recovery in a patient who 
is the subject of lithotomy. 
Surgical skill constitutes another element of success. In this I would in- 
clude not only the operative tact which enables the surgeon to execute, by 
clean and well-directed incisions, the division of the perineal and vesical struc- 
tures and the extraction of the calculus without unnecessarily damaging the 
bladder or the prostate, but also the exercise of a discriminating judgment 
in the selection of proper cases for cutting, together with a watchful and 
judicious management of the case after the operation has been performed. 
Dudley, in 207 cases, is said to have lost only 6, or 1 in 34J ; Mott, in 162 
cases, lost 7, or 1 in 23; Mettauer, in 91, lost 4, or 1 in 22|; Gross, in 140, 
lost 12, or 1 in Ilf. The average mortality with American surgeons, based 
on an analysis of 2303 cases, is about 1 in every 14f.* This is almost identical 
with the death-rate of an eminent native Indian surgeon, Raj Ran Nasian 
Dass Bahadoor, of Calcutta, who in 248 cases of lateral lithotomy lost 17, 
or 1 in 14f. G. Bainbridge, of India, in 199 lateral lithotomies, lost 6 patients, 
-a death-rate of nearly 3 per cent. 
The most remarkable success attained by any single operatoi- is that of 
Martineau, of Norwich, England, wTho lost only 2 in 84 cases. Thompson, 
however, who has carefully analyzed the cases of this operator, finds that 
34 were under fifteen years of age, 6 were females, and not over 12 were 
more than sixty years of age. Such a revelation lessens very much our sur- 
prise at what, under other circumstances, would seem a very exceptional 
success. 
Dudley lost only 6 patients in 207 cases, or 1 in 34j; but about 150 of these 
were under fifteen years of age. Professor Gross, in 66 operations on chil- 
dren, lost but 1 case. 
Success is sometimes attributed to luck, or good fortune, as it is termed, 
but, although the planets do not rule in the domain of surgery, and good re- 
sults are generally attributable to the skill and judgment of the operator, no 
amount of manual dexterity in the use of the knife or of professional wisdom 
will prevent a certain number of patients from dying. It is very unwise for 
a surgeon to become too much elated by a long run of success. For several 
years-one year seven times-I cut patients for stone without the loss of a 
single case, when I became disposed to criticise the average mortality of the 
operation; but immediately afterwards I lost three cases in rapid succession. 
The season of the year has sometimes been supposed to exert some influence 
on the mortality of lithotomy. I find, however, no sanction for this belief 
in the records of the operations which I have examined. 
Relapse.-In 4902 cases of lithotomy, drawn from the statistics furnished 
by Mr. Williams from the Norfolk and Norwich Hospitals, from those also of 
* Gross on the Urinary Organs, p. 275.  INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
two great hospitals in France,-La Charite and Luneville,-from the Saha- 
nunpore Dispensary, India, and from 1100 cases which I have had collected 
from various sources since 1875, only 45 relapses are noticed,-less than 
1 in every 100. No reliance, however, can be placed upon statistics of this 
kind. Many persons cut for stone pass from under the observation of 
the original operators and fall into the hands of other surgeons, while no 
record is kept of theii- history which ever finds its way into those channels 
which are accessible to statisticians. It is in the highest degree probable 
that a much larger ratio of relapses occurs than is represented in tables con- 
structed with a view, in part, of developing this information. In two in- 
stances I cut patients who had been twice operated on before,-one a man 
over seventy, and the other in middle life. Twice I have performed lithotomy 
in children who had been subjected to the operation once before. The most 
extraordinary instance of multiple lithotomy was that of a military surgeon, 
Maldigny, reported in the "London Medical and Surgical Journal," vol. v. 
p. 264. He had been the subject of lithotomy six times, and of lithotrity 
twice. Once the patient cut himself, guided by the reflection from a mirror 
placed beneath the perineum, and extracted a calculus from the neck of the 
bladder. 
A person who is left after lithotomy with a fistula, or one who, suffering 
from chronic cystitis, has been the subject of phosphatic calculus, is liable to 
a return of the disease. It has happened in some cases that a second stone, 
or a fragment of a broken one, has been overlooked at the time of the opera- 
tion, and the reappearance of the vesical symptoms of stone has been 
ascribed to relapse. In other cases when relapse follows, the surgeon may 
be subjected to very unjust criticism, under the impression that he failed to 
discover all the concretions present at the time the lithotomy was done. 
As an illustration of this, I may mention that I once cut a child for stone, 
extracting a calculus the size of a pigeon's egg. Symptoms indicative of the 
presence of a second concretion reappeared after the lapse of three months. 
I again operated, removing a second stone quite as large as the first. The 
little patient recovered from the operation, but died six months later from 
disease of the kidneys. The autopsy explained the apparent relapse, as 
the left ureter was enormously dilated and packed with calculi of consid- 
erable size. It was from this source that the two calculi which had been 
formerly removed had come. 
Indeed, stone, depending as it generally does on a disturbed or deranged 
condition of the digestive apparatus and a faulty action of the kidneys, might 
very naturally be expected to recur. 
684 
Median Lithotomy. 
In median lithotomy the incisions are made in the middle of the perineum, 
beginning in the raphe between the scrotum and the anus. This operation 
was first proposed by Manzoni, a surgeon of Verona, Italy, in 1808, and after- 
wards practiced by two of his countrymen, Rizzoli and De Borsa. It is some- 
times described as a revival of the old Marian method, or that performed by 
Marianus Sanctus, who, it is said, learned the route to the bladder from his 
preceptor, Franciscus de Romani, of Cremona, Italy. It was also known 
as the method by the apparatus major. The modern operation, however, 
differs from the Marian in the simplicity of the instruments with which it is 
executed. 
As performed by De Borsa, the patient was placed in the same position as 
for the lateral operation, on the back, with the limbs flexed on the body and 
abducted. A staff, with its groove in the centre, was passed into the bladder, 
and held by an assistant well up under the pubic arch, while the surgeon 
made an incision in the median line extending from the scrotum to the anus, 
which was carefully deepened until the membranous part of the urethra was 
reached; this was freely opened along its whole extent on the groove of the MEDIAN LITHOTOMY. 
685 
staff, a distance of about three-quarters of an inch. This done, the index 
finger was carried along the staff into the bladder, dilating in its progress 
(by a series of boring movements) the prostatic portion of the urethra. As 
soon as the bladder had been reached, the staff was withdrawn, a pair of 
forceps conducted into the viscus along the finger as a guide, and the stone 
seized and extracted. It will be readily perceived that such an operation is 
adapted only to the extraction of calculi of small size. A large stone could 
not fail to lacerate the prostate during its passage through that body, an 
accident which is also likely to occur at the time of the forcible introduction 
of the finger. This plan is sometimes termed lithectasy. Vacca, in order to 
avoid an accident of this nature, extended his incision beyond the limits of 
the membranous portion of the urethra into the prostate body. Mr. Allarton, 
of England, performed this median operation in a manner somewhat different 
from that of De Borsa. Instead of making formal incisions from the surface 
inward, he introduced the index finger of the left hand into the rectum, 
allowing its top to rest against the anterior surface of the prostate and upon 
the staff. A long, straight, double-edged knife was next thrust into the 
perineum about five-eighths of an inch in front of the anus; this was carried 
steadily onward and a little upward, until its point, guided by the finger in 
the bowel, entered the groove of the staff, when it was made to divide the front 
of the prostate, the external wound being enlarged to the extent of one inch 
in a downward direction. As the knife was withdrawn, a long ball-pointed 
probe was passed through the wound into the bladder along the groove of the 
staff; after which the latter was removed, and a fingei' inserted into the incision 
and carried down to the probe and along the latter into the bladder, when 
the forceps were introduced along the finger and the calculus removed. 
When the calculus was large, Mr. Allarton used either the three-bladed female 
dilator of Weiss or the hydraulic expander of Arnott, in order to stretch the 
prostate. Teale and Dolbeau also employed instruments for dilatation. 
Much harm would be likely to follow such procedures, especially in children, 
in whom the prostate is small and the fascial attachment of the neck of the 
bladder loose. In his later operations Mr. Allarton discarded all dilators ex- 
cept the finger, and also insisted in cases of large stone on breaking the calculus 
before attempting its extraction. In this country the median operation was 
practiced almost exclusively by the late Dr. Walters, of Pittsburg. In New 
York it has received the support of Dr. Markoe and of Dr. Little. 
The advantages which are thought to belong to this operation are-first, 
the little dangei' of hemorrhage, from there being no vessels of magnitude in 
the track of the incisions; secondly, confining the nicking of the prostate to 
the middle line of the body; thirdly, the slight risk of wounding the vesiculse 
seminales, and the trifling disturbance of the recto-vesical fascia, thus lessen- 
ing the probability of urinary infiltration; fourthly, the simplicity of the 
procedure. 
On the othei' hand, there are certain disadvantages connected with the 
median operation which rendei' it inferior to the lateral method. First, 
the space between the neck of the bladder and the rectum is so narrow 
. that the latter is greatly exposed to injury below, while the bulb of the 
penis is equally in danger in front. In children this objection is particularly 
forcible. Secondly, the bladder is more liable to be pushed before the finger 
during the efforts made to enter its cavity, and the prostate more likely to 
be torn, than in lateral lithotomy. Finally, it is entirely unsuited to the 
extraction of large stones, as has been shown by Mr. Williams, who, in ana- 
lyzing the cases of stone operated on by the median plan at the Norfolk and 
Norwich Hospitals, found that only in a single instance did a patient survive 
when the stone exceeded three drachms and a quarter in weight, or when the 
long diameter of the stone exceeded one and one-half inches and the short 
diameter one and one-eighth inches. In the instance referred to, the calculus 
weighed four and one-eighth ounces, and its extraction was followed by 
sloughing of the rectum and perineum, and the entailment of a peri neo-recto- 686 
vesical fistula. As to the healing of the wound, the time required for that 
purpose differs very little in the median and lateral methods. 
In determining the value of the median operation, resort must be had to 
statistical information. The tables of Mr. Allarton, numbering 170 cases, 
are not admitted even by English authorities as furnishing reliable data for 
the decision of this question. Mr. Williams has collected 64 cases of median 
lithotomy performed at the Norfolk and Norwich Hospitals, of which number 
13 died, or nearly 1 in 4. Of 64 lateral lithotomies performed in the same 
hospitals and under, approximately, the same conditions as to age, etc., 8 
died, or 1 in 7. 
Still later, McCadge, from the same hospitals, collected 90 cases of median 
lithotomy, of different ages, with 16 deaths,-a mortality of 17.77 per cent. 
The table of Gross, which includes the 64 cases of Mr. Williams,* with 
205 drawn from the practice of American surgeons, 56 from Beyer, of Cairo, 
and 25 from Pemberton, of Birmingham, constituting in the aggregate 350 
cases of median lithotomy, furnishes 318 recoveries and 32 deaths, or 9.14 
per cent., which is a higher mortality than that following lateral lithotomy 
if the death-rate of the latter is 1 in 21, as appears to be the case. 
The following cases of median lithotomy have been published since January 
1, 1875: 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
No. 
Age. 
Weight of Stone. 
Recovered. 
Died. 
Source of Information. 
1 
2 J years 
150 grains. 
1 
1 
2i 
c< 
30 " 
1 
1 
3 
cc 
20 " 
1 
1 
4 
CC 
135 " 
1 
1 
5 
cc 
65 " 
1 
1 
6 
cc 
102 " 
1 
1 
7 
CC 
120 « 
1 
1 
9 
cc 
135 " 
1 
1 
10 
cc 
135 " 
1 
1 
10 
cc 
370 " 
1 
1 
10 
cc 
79 " 
1 
Lancet, March 18,1876, p. 423. 
1 
11 
cc 
380 " 
1 
All done at Lexington Infirmary. 
1 
11 
cc 
212 " 
1 
1 
40 
cc 
750 " 
1 
1 
50 
CC 
436 " 
1 
1 
60 
a 
232 " 
1 
1 
61 
cc 
Not stated. 
1 
1 
62 
cc 
CC cc 
1 
1 
63 
cc 
325 grains. 
1 
1 
70 
CC 
495 " 
1 
1 
35 
cc 
3 stones, each J 
1 
British Medical Journal, January 8, 
inch in diam- 
eter. 
1876. 
1 
52 
cc 
140 grs., 1| by 
1 
British Medical Journal, December 
1 inch. 
7, 1878. 
1 
69 
cc 
3 stones, 2 of 60 
1 
Lancet, June 5, 1875. 
grs., 1 of 36 
grs. 
1 
17 
Catheter for nu- 
1 
Philadelphia Medical Times, 1878, 
cleus 9 inches 
long. 
p. 106. 
1 
50 
cc 
Not stated. 
1 
Dublin Quarterly Journal, vol. Ixiv. 
p. 390, 1877. 
1 
40 
cc 
CC cc 
1 
Dublin Quarterly Journal, vol. Ixiv. 
p. 391, 1877. 
1 
20 
cc 
cc cc 
Not returned. 
St. Bartholomew's Hosp. Bep., vol. xi. 
1 
20 
cc 
420 grains. 
1 
Medical Record, vol. x. p. 584. 
1 
3i 
cc 
Not stated. 
1 
Medical Record, vol. xii. p. 531. 
1 
36 
60 grains. 
1 
Lancet, June 5, 1875, p. 290. 
30 
26 
3 
* Holmes's System of Surgery, vol. iv. p. 1079. The cases number 30, 26 of which were cured, 3 died, and 1 was doubtful, 
-a mortality of 11.5 per cent., not far from that obtained by Gross from his 
350 cases. Of the fatal cases, 1, aged fifty-two, died of shock, sixteen hours 
after the operation; 1, aged three and one-half years, died of pyaemia; the 
cause of death in the third is not mentioned. 
Modifications.-The modifications of Allarton's operation consist in the 
manner of exposing the staff*, and in the instruments used for guiding the 
knife and finger into the bladder. Thus, Thompson reached the staff by 
cutting from before backward, and Erichsen before passing the finger into 
the bladder introduced a blunt-pointed director along the groove for the 
guidance of the digit, the staff not being removed from the viscus until the 
finger had reached its cavity. Markoe and Little altered the groove of the 
internal staff, making it broader, in order that it might be more easily reached 
MEDIAN LITHOTOMY. 
687 
Fig. 1416. 
Little's director. 
with the knife. The latter surgeon also employed a grooved director (Fig. 
1416), which wras designed as a substitute for the probe of Allarton. 
Medio-Later al Operation. 
The median operation has been variously modified. Professor Buchanan, 
of Glasgow, employs for the purpose a rectangular staff (Fig. 1417), the 
Fig. 1417. 
Buchanan's staff. 
short limb of the angle being three inches in length, and having on its left 
side a deep groove. The staff is introduced into the bladder, and, with a 
finger in the rectum, its ahgle is adjusted to the apex of the prostate body. 
The handle is next carried towards the abdomen, making the angle of the 
staff quite prominent in the perineum. The surgeon now, still keeping the 
index finger in the rectum, pushes a long narrow-bladed and sharp-pointed 
knife in front of the anus onward through the perineum, with the blade 
horizontal and turned towards the left side, until the point enters the groove 
in the staff, and thence onward until the knife is arrested by the stop at the 
end of the groove. (Fig. 1418.) The escape of the water through the 
wound announces that the bladder has been entered, whereupon the knife is 
withdrawn; in doing this it is made to divide the tissues on the left side of 
the perineum, in the direction of the tuber ischii, in a curvilinear manner, and 
to the extent of one inch and a half. The operation is a medio-lateral one, 
though the membranous part of the urethra is left untouched. The subse- 
quent steps towards the extraction of the calculus are the same as in ordi- 
nary lateral lithotomy. The advantages claimed for this operation are 
rapidity of execution, and diminished risk of hemorrhage and of urinary 
extravasation into the recto-vesical space. Of 64 patients cut by this plan, 6 
died, or 9.3 per cent. 
Mr. Henry Lee's method of performing medio-lateral lithotomy consists 688 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
in passing a staff into the bladder, the patient being in the usual position for 
lithotomy; the scrotum is then held well up, and an incision made in the 
median line of the perineum from 
before backward, stopping a few 
lines in front of the anus, from 
which point the incision is pro- 
longed around the front and left 
side of the rectum, forming a 
curved figure. The index finger 
is next inserted into the wound, 
and, while the rectum is pressed 
back, a few touches of the knife 
will serve to detach the bowel 
still more from the parts in front. 
Withdrawing the finger from the 
wound, it is now introduced into 
the rectum, and, using it as a 
guide, the knife, with its back 
towards the bowel, is carried in 
the middle line into the groove of 
the staff through the membranous 
part of the urethra ; after which it is withdrawn, and another, with a probe 
point, passed into the groove and pushed onward into the bladder, and a 
lateral incision of the prostate made from within outward. 
Fig. 1418. 
Incision of the perineal structures and of the prostate on the 
rectangular staff. 
Bilateral Lithotomy. 
Bilateral lithotomy, believed to have originated with Ee Dran, was in 1824 
formularized more particularly by Dupuytren. In the United States its most 
powerful advocates have been Professor Paul Eve, Professor Briggs, of Nash- 
ville, Tennessee, and Professor Hughes, of Keokuk, Iowa. 
The operation is performed by introducing a staff with a median groove 
into the bladder, making a semilunar incision with a bistoury across the 
perineum about three- 
quarters of an inch in 
front of the anus, be- 
ginning midway between 
the anus and the tuber 
ischii on one side, and 
terminating at a corre- 
sponding point on the 
opposite side. After the 
first cut is made the 
wound is erroneously said 
to become straight, lying 
directly across the peri- 
neum. (Fig. 1419.) A 
finger is now introduced 
into the opening, and the 
rectum pressed back as 
the deeper parts are di- 
vided until the staff is 
reached and the mem- 
- . . . . u branous urethra laid 
open. The scalpel is now laid aside, and, with the nail of the finger resting 
on the edge of the staff, the beak of the double lithotome cache (Fig. 1420) 
is conducted into the groove with the concavity of the instrument directed 
upward. Sliding the lithotome up and down, so as to be sure of its position 
in the staff, the operator now takes the latter from the assistant into his own 
Fig. 1419. 
Incision in bilateral lithotomy. BILATERAL LITHOTOMY. 
689 
hand, depresses the handle on a level with the pubes, at the same time 
lowering the lithotome and pushing it onward into the bladder. This accom- 
Fig. 1420. 
Double lithotome cache. 
plished, the staff is to be withdrawn and the lithotome reversed, so that its 
concavity shall be directed downward, or towards the rectum, when it is to 
be withdrawn, at the same time expanding the blades by pressing the spring 
attached to the handle. As the instrument is brought out, both lobes of the 
prostate are divided in a somewhat crescentic manner. The finger is at once 
carried through the wound into the bladder and touches the stone, and, having 
thus learned its location, the 
operator effects its extraction 
as in lateral lithotomy, by the 
forceps. (Fig. 1421.) 
In 1836, Civiale introduced 
a modification of the bilateral 
method, which he termed medio- 
bilateral lithotomy. A staff 
with a median groove being 
passed into the bladder, an in- 
cision in the median line of the 
perineum was made one inch 
and a half in length, anterior 
to the anus, and down to the 
membranous urethra. The lat- 
ter being then opened, a double 
lithotome cache, in most re- 
spects similar to that of Dupuy- 
tren, and closed, was inserted into the groove of the staff and carried onward 
into the bladder. The blades of the instrument were then expanded, and as 
it was withdrawn the prostate was divided on either side. The finger then 
followed the staff into the bladder, when the staff was withdrawn, the forceps 
introduced, and the calculus removed. 
The operation differs from the bilateral in the median instead of the semi- 
curvilinear incision of the perineal structures. 
Two other modifications of the bilateral method have been practiced. The 
first was that of Sir William Fergusson, who, in making the external incisions 
into the perineum, united to the semi-curvilinear cut of Dupuytren a second 
in the middle line, with a view of obtaining a large external wound. The 
othei- was by Nelaton, who divided the perineum transversely about three- 
eighths of an inch in front of the anus. This was the prerectal method. 
Bilateral lithotomy is not likely to become popular either in this country or 
in Great Britain. The division both of the perineum and of the prostate is 
entirely too extensive in most instances for the necessities of the operation. 
In addition to this, both the rectum and the bulb of the corpus spongiosum 
are more exposed to injury than by the lateral plan. The results, however, of 
the operation are not less favorable than those obtained by any other method. 
Professor Briggs, of Nashville, Tennessee, has performed the operation in nine 
cases without a death. Dr. Campbell, of Augusta, Georgia, records 41 cases 
of bilateral lithotomy, with 2 deaths, or 1 in 20. Twenty-one of the patients 
were children, all of whom recovered; and twenty were adults, with two 
deaths. In 536 cases recorded by Gross there were 41 deaths, or 7.64 per cent. 
Fig. 1421. 
The three primary or fundamental incisions,-median, lateral, 
and bilateral. 690 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
Recto-Vesical Lithotomy. 
Recto-vesical lithotomy, according to Clot Bey, has been practiced time 
out of mind in Egypt: it was introduced into France by Sanson in 1816, 
who, before attempting the operation on the living subject, proved it prac- 
ticable on the cadaver. Barbantini by this method removed a calculus 
weighing nine and a half ounces. It is rarely performed at the present 
time. 
The operation is executed as follows. A staff with a median groove is 
carried into the bladder and intrusted to an assistant. The surgeon inserts 
his left index finger into the rectum with its palmar surface upward. Along 
the digit a straight-bladed bistoury is carried flatwise until the anterior bor- 
der of the prostate is reached, when the instrument is turned with the edge 
of the blade directed upward, and made to penetrate the anterior wall of the 
intestine and enter the groove of the staff through the membranous urethra, 
when, by drawing the bistoury backward, the rectum, a few fibres of the 
levator ani, and the sphincter ani, together with the fascia and integument, 
are divided to the extent of about one inch in front of the anus. Reversing 
now the edge of the knife, and placing its point in the groove of the staff, it is 
pushed onward through the prostate body and the neck of the bladder, and 
into the vesical triangle. Through this opening the forceps is inserted, and 
the stone extracted after the withdrawal of the staff. The modifications which 
have been made of the recto-vesical method are those of Maisonneuve and 
Bauer. The former opened the bladdei' without dividing the sphincter ani, 
and the latter accomplished the same object by exposing the cavity of 
the rectum with a strong duck-bill speculum, and through it cutting into 
the bladder behind the prostate, and, consequently, through the trigonum 
vesicse without dividing the perineum,-an operation infinitely superior to 
the old plan. After the removal of the stone the wound is to be closed by 
silver sutures. Professor Bauer, in 1859, succeeded in curing a case in this 
manner. A similar success was obtained by Dr. Noyes. 
There are, however, certain dangers connected with recto-vesical lithotomy 
which render it exceedingly improbable that the operation will ever become 
an established surgical procedure. The evils alluded to are urinary infiltra- 
tion, inflammation and suppuration of the recto-vesical fascia, injury to the 
vesiculae seminales or their ducts, and recto-vesical fistula. 
Professor Vacca observes that of seven patients operated on by the above 
method, four suffered from recto-vesical fistula. Professor Gross speaks 
of a similar termination in three out of four cases. Dupuytren, who per- 
formed the operation six times, lost one-half of his cases from diffuse inflam- 
mation of the pelvic fascia. 
The mortality which has followed the operation is also calculated to add 
to its condemnation. Of 83 cases of the operation collected by Konig,* 67 
were cures, 11 recovered with fistula, and 16 died, a mortality of 23.88 per 
cent. It would be much better, in case of a stone being too large for lateral 
or bilateral lithotomy, to adopt the supra-pubic plan for its extraction rather 
than the recto-vesical method. 
The operation of opening the bladder above the pubes has been designated 
by different names, as the supra-pubic, the high operation, cystotomia epigas- 
trica, and epicystotomia. The introduction of this method for the extraction 
of urinary calculi is attributed to Peter Franco, in 1561, though it had been 
suggested by Archigenes. In England the operation received very little atten- 
tion until after it was executed by Proby, when it rose into some notoriety, 
chiefly through the influence of Douglas, Cheselden, Prye, and others. Che- 
selden after a time abandoned it for the lateral operation; and notwithstand- 
ing it again attained some reputation through the successes of Frere Come, it 
generally fell into disuse, unless when called into requisition on account of a 
Supra-Pubic Lithotomy. SUPRA-PUBIC LITHOTOMY. 
691 
calculus being too large for extraction by other methods. At a later period, in 
Paris, it was revived by Souberbielle, receiving also the sanction of Carpue, 
Home, and Scarpa, all of whom were the authors of special papers on the 
subject, as also were Dzondi, Amussat, and Leroy d'Etiolles. In this country 
the first operation of the kind was performed by Professor William Gibson, 
of the University of Pennsylvania, on a patient suffering from calculus, but 
w'hose prostate was so much enlarged that it was not deemed advisable to 
approach the bladder through the perineum. The case proved fatal from 
urinary infiltration producing peritonitis. The supra-pubic operation was also 
practiced to some extent by Dr. Carpenter, of Lancaster, Pennsylvania. 
Operation.-The patient is placed in the recumbent position, with the 
pelvis at the end of a narrow table and somewhat elevated, and the limbs 
and feet supported on a chair. The head and shoulders are slightly raised 
upon a pillow, in order that the abdominal parietes may be relaxed. The 
hair is next to be shaven from the pubes, after which it is advised to distend 
the bladder well with wyater. Though I have never performed the oper- 
ation on the living subject, yet from my observations on the cadaver I feel 
satisfied that the danger of urinary infiltration is lessened by allowing the 
viscus to remain empty. An incision must now be made exactly in the 
linea alba, beginning at the pubes, and extending upward about three and 
a half or four inches. The skin and superficial fascia being divided, the 
aponeurosis of the external oblique is carefully opened in the median line on 
a director to the extent of two inches. On clearing away With a few touches 
of the knife some loose cellular tissue, the bladder is exposed in a space 
where it is not covered by the peritoneum. A catheter with a long curve 
should now be introduced into the bladder, and depressed between the thighs 
of the patient until its point is brought up against the summit of the bladder, 
and the latter raised towards the wound. (Fig. 1422.) Retractors being 
now placed on the sides of the external 
opening in the soft parts so as to keep 
them asunder, a tenaculum is hooked 
into the walls of the protruding bladder, 
in order to hold it securely in place 
during the succeeding steps of the opera- 
tion. 
While the viscus is thus held, an in- 
cision three-quarters of an inch long is 
made through its anterior wall close be- 
hind the pubes. Without inserting the 
finger for the purpose of locating the 
calculus, let the forceps be immediately 
introduced, and the stone seized and 
extracted. This accomplished, the open- 
ing in the bladder should be united by a 
sufficient number of interrupted earbolized catgut sutures; after which the 
parietes must be brought together by silver sutures or by the hare-lip suture, 
first depositing in the supra-pubic space a drainage-tube, which is to be brought 
out of the lower angle of the wound. The patient is now put to bed, and 
the urine drawn with a soft catheter every foui' or six hours, so as to pre- 
vent any considerable accumulation until the walls of the bladder have 
united. 
The advantages claimed for the supra-pubic operation are its freedom from 
hemorrhage, the absence of danger to the rectum, neck of the bladder, 
prostate body, and vesiculse seminales, and of difficulties arising from stricture 
of the urethra or deformity of the pelvis, as well as its applicability to cases 
of very large calculi, which could not be safely extracted by any of the peri- 
neal methods. Over against these advantages may be placed the great danger 
to the peritoneum, the risk of urinary extravasation into the cellulai' tissue 
of the pelvis, and the unfavorable position of the wound for drainage. 
Fig. 1422. 
Opening through the parietes of the abdomen, 
and the bladder protruded into the opening by the 
catheter. 692 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
In determining the true merits of the operation it will be proper to gather 
such information as may be gleaned from statistical data. 
Dr. Dulles has collected 493 cases of supra-pubic lithotomy, of which number 
336 recovered and 137 died. Of these, 43 were operated on by American sur- 
geons, with the following result: 28 recovered, 14 died, and in 1 the termi- 
nation is not noted, a mortality of 32.55 per cent. Adding to this collection 
3 later operations, namely, one by Amussat,* one by Fowler,f and one by 
Hutchinson,J we have a total of 496 cases, with 358 recoveries and 138 
deaths, a mortality of 27.82 per cent. 
Though the fatality appears very great, yet when it is considered that 
many of the cases subjected to this method were in consequence of the 
magnitude of the stone deemed unsuited to any other operation, and that in 
others the supra-pubic plan was adopted after the lateral method had failed, 
the results are not worse than those obtained from perineal operations. To 
state it in other words, lateral lithotomy for stones of all sizes is four times 
more successful than the supra-pubic operation, but when the calculus exceeds 
two ounces in weight the results are almost as markedly in favor of the latter 
method. With those between one and two ounces the mortality differs very 
little in the two operations, and when the calculus was less than one ounce 
the lateral operation proved by far the more successful. In support of this 
conclusion, a number of cases operated on by the lateral and by the supra- 
pubic method are contrasted in the following table: 
• 
Lateral Operation. 
Supra-Pubic Operation. 
Weight. 
Recovered. 
Died. 
Total. 
Death-Rate. 
Recovered. 
Died. 
Total. 
Death-Rate. 
Under 1 ounce 
482 
47 
529 
11 
3 
14 
1 to 2 ounces 
101 
18 
119 
15.12 " 
17 
4 
21 
19 04 " 
2 to 3 ounces 
19 
16 
35 
45.71 " 
10 
4 
14 
28.57 " 
3 to 4 ounces 
4 
7 
11 
63.63 " 
13 
6 
19 
31.57 " 
4 to 5 ounces 
2 
3 
5 
60.00 " 
9 
7 
16 
43.75 " 
5 to 6 ounces 
2 
2 
00.00 " 
7 
4 
11 
36.36 " 
6 to 7 ounces 
2 
2 
100.00 " 
1 
1 
2 
50.00 " 
With regard to sex, 35 cases of females operated on by the lateral plan are 
contrasted with 82 in which supra-pubic lithotomy was adopted; 33 recover- 
ing and 2 dying, or 5.71 per cent., by the former, and 72 recovering and 10 
dying, or 12.19 per cent., by the latter method. 
Upon comparing the different methods practiced for the extraction of stone 
by incision, we find in 11,342 cases of lateral lithotomy 1220 deaths, a mor- 
tality of 10.75 per cent.; in 577 bilateral lithotomies, 43 deaths, a mortality 
of 7.45 per cent.; in 380 median lithotomies, 35 deaths, a mortality of 9.21 
per cent.; in the recto-vesical operation, 83 cases, with 16 deaths, a mortality 
of 19.27 per cent.; and in the supra-pubic operation, 465 cases, with 135 
deaths, a death-rate of 29.03 per cent. 
The result of this comparison of methods is in favor of the bilateral opera- 
tion to the extent of four per cent, of cases. But the numbers compared are 
so unequal that it is not safe to make the difference a basis for a dogmatic 
deduction. 1 doubt not that the highest success in lithotomy would be ob- 
tained if the median operation were selected for small calculi, the lateral for 
stones of medium size, the bilateral for stones above the medium size, and the 
supra-pubic for such as are of great magnitude, weighing, for example, four 
ounces and upward. 
* American Journal of the Medical Sciences, p. 257, January, 1877. 
f British Medical Journal, p. 369, September 7, 1878. 
j Ibid., p. 608, October 19, 1878. LITHOTOMY IN THE FEMALE. 
693 
In summing up the subject of dealing with vesical calculi, the following 
rules may be laid down for the guidance of the practitioner: 
1st. All cases of calculus occurring in infancy and childhood should be 
lithotomized. 
2d. All cases occurring in adults in which the stone is soft, and not too 
large, should be treated by lithotrity. 
3d. Even cases of hard stones, consisting chiefly of oxalate of lime (pro- 
vided the concretion is small), and especially if there is any evidence of the 
existence of renal disease, should be treated by lithotrity. 
4th. All cases not included in the above category are proper subjects for 
lithotomy. The particular method of the operation is to be determined by 
the magnitude of the calculus. 
5th. Calculous patients suffering from serious structural disease of the kid- 
neys are unsuited for either lithotomy or lithotrity, and should be content 
with palliative treatment. 
Lithotomy in the Female. 
In consequence of the dilatability and shortness of the urethra, females 
are rarely the subjects of vesical calculus. As compared with males, the 
proportion is about one of the former to twenty-one or twenty-two of the 
latter. In consequence of the slight depression of the bas-fond of the 
bladder below the urethra, any concretion which may pass down from the 
kidneys is readily swept into the latter by the current of the urine, and thus 
escapes. The middle period of life is that in which females are subject to 
stone. In some instances the calculi attain an extraordinary size. In two 
cases I have known the concretion to reach the size of a goose-egg. These 
calculi are sometimes discharged spontaneously, either through the urethra 
or by ulceration, into the vagina. A number of examples of stones of large 
size having passed through the urethra have been recorded by writers. The 
most remarkable is that given by Molyneaux, in which a woman passed a 
calculus measuring seven inches and six-tenths in length, and five inches and 
three-quarters at its point of greatest thickness. Somewhat similar cases 
are given by Heister, Sir Astley Cooper, and others. An instance of a cal- 
culus the size of a goose-egg finding its way into the vagina by ulceration 
came under my own observation. Singularly enough, the opening closed up 
without leaving a fistula. In anothei- case a large phosphatic calculus passed 
into the vagina from the dilated ureter by a similar process. This patient 
had suffered for several years from great vesical distress. The bladder had 
been repeatedly sounded for stone, without any being detected. Finally, 
during a paroxysm of tenesmus, and simultaneously with the escape of an 
enormous concretion into the vagina, the lady expired. 
Symptoms.-The signs of calculus in the female are frequent micturition, 
vesical tenesmus, pain, often extending down the thighs, and, finally, inconti- 
nence of urine. As in the male, so in the female, sounding furnishes the only 
certain evidence of the existence of a calculus. For this purpose, a short 
steel sound, very slightly curved at its vesical extremity, is to be inserted into 
the bladder, and carried about in various directions, while the patient is placed 
on her back at the edge of the bed, with the limbs drawn up and the feet 
resting on two chairs. The exploration may require to be aided by a finger 
introduced into the vagina, or, in the case of children, into the rectum, so 
as to raise dependent portions of the bladder into a favorable position for 
searching with the sound. 
Treatment.-There are three methods for the extraction of calculi from 
the female bladder, namely, by dilatation, by crushing, and by incision. 
Dilatation-lithectasy-consists in stretching the urethra, either gradually 
or rapidly, to an extent sufficient for the introduction of the forceps and the 
delivery of the stone. This procedure was no doubt suggested by the occa- 
sional spontaneous passage of very large calculi through the urethra, some 694 
INJURIES AND DISEASES OF THE GENITO-URINARF ORGANS. 
of which have already been alluded to, and others have been recorded by 
Middleton, in his treatise on supra-pubic lithotomy, and also by Colot, in his 
" Trait6 de 1'Operation de la Taille." 
The gradual dilatation was formerly effected by sponge-tents of increasing 
sizes. Thomas, in this way, extracted an ear-pick from the bladder. This 
plan, however, is not regarded with much favor at present, as it has been 
found to have a tendency to produce urinary incontinence. 
Rapid dilatation is to be preferred, and may be accomplished in one or two 
minutes by passing an instrument (Fig. 
1423), closed, into the bladder through the 
urethra, and then expanding the blades to 
the required degree. 
I have accomplished the purpose per- 
fectly by using, in succession, first the little 
finger, previously well oiled, then the ring 
finger, and last the middle finger. By this 
method I have removed a flat calculus three 
inches in circumference. For a long time 
afterwards, however, the patient suffered 
from incontinence. The relative frequency of incontinence following slow 
and rapid dilatation has been examined by Bryant, who found that in 13 
cases of slow dilatation 4 were followed by incontinence, while in 15 cases of 
rapid dilatation not one was followed by this infirmity.* 
When a stone exceeds one inch in diameter, it is not advisable to remove 
it through the urethra. Mr. Bryant, who has given much attention to this 
subject, fixes the limit at two inches in circumference. The patient, pre- 
viously etherized, should be placed on the back, across the bed, with her hips 
resting on its edges, the feet supported on a stool, and the limbs widely sepa- 
rated. As soon as the dilatation has been effected, the forceps are to be in- 
troduced, and the stone grasped, taking care to seize it in such a manner 
that its smallest diameter shall present, when, by a gradual and steady 
traction, the concretion can be drawn through the urethra. 
Lithotrity.-When the calculus cannot be safely extracted through the 
urethra, either on account of its size or from some peculiarity in its shape, 
lithotrity offers the most certain and effectual method of disposing of the 
body. The lithotrite is to be introduced into the bladder, and the stone 
caught and crushed into pieces sufficiently small to admit of their being ex- 
tracted by the forceps, and by aspiration, at one sitting. 
The operation is much easier than in the male, and should always be 
adopted when it is deemed inadvisable, from the size, density, and roughness 
of the stone, to resort to extraction through the urethra. The procedure 
is a very successful one. Of 13 cases analyzed by Bryant, all recovered, 
though in one incontinence followed the operation. 
Lithotomy in the female may be performed through the urethra, through 
the vagina, or above the pubes. 
Urethral lithotomy is an exceedingly simple procedure. 
Different operators have made their incisions in different directions. Brodie 
divided the parts directly upward towards the pubes, Colot in the opposite 
direction, or downward, and Liston preferred a horizontal cut, nicking the 
urethra on each side, and then dilating. The oblique unilateral plan is to be 
preferred. In the execution of this operation the patient is placed on her 
back, as in lithotrity, having been previously etherized. A grooved director 
(Fig. 1424) is passed through the urethra into the bladder, and its groove 
turned towards the left side; an incision is made on the instrument with a 
probe-pointed knife, extending through the urethra into the neck of the 
bladder, and prolonged outward, and carried downward towards the left 
tuber ischii to the extent of one inch, observing not to carry the incision too 
near the ramus of the ischium and thus endanger the internal pudic artery. 
Fig. 1423. 
Instrument for dilating the female urethra. 
* Medico-Chirurgical Transactions, vol. i. p. 123. VAGINAL LITHOTOMY. 
In one modification of the bilateral operation, a similar cut is made on the 
opposite side of the perineum. The bladdei* being opened, the finger guides 
695 
Fig. 1424. 
the forceps into the viscus, when the stone, being grasped between the ex- 
panded blades of the instrument, is extracted. Formerly it was the practice 
to allow the incision to heal by open granulation, and the consequence was 
that incontinence of urine followed the operation in many cases,-nine times 
in twenty patients, according to the collection of Bryant. At the present 
time, when such a procedure is demanded, the parts are brought together 
by deep interrupted silver-wire sutures, and the urine drained away by a 
Sims catheter. In this way the voluntary retentive power of the neck of 
the bladder is restored, and incontinence obviated. 
Staff for female urethral lithotomy. 
Vaginal Lithotomy, in cases of large stones, is the proper operation. 
Rousset was the first to open the bladder through the vesico-vaginal septum. 
The operation was sanctioned by Vidal. Since the introduction of the 
silver thread, and its application to the treatment of vesico-vaginal fistula, 
colpo-cystotomia, as it has been termed, may be regarded as an established 
surgical operation. It has met the approbation of Dr. Sims and of Dr. 
Emmett in this country; and in England it has a strong advocate in Dr. 
Aveling.* 
Operation.-The patient should be placed across the bed, on her side, 
with the limbs drawn up and the trunk flexed on the pelvis, or she may, 
preferably, be placed on the breast, with a low box, which has been covered 
with a blanket or comfortable, thrust under the abdomen, in order to 
elevate the hips. The limbs, being bent back, are committed to assistants, 
one of whom at the same time holds the vagina open by a duck-bill speculum. 
The surgeon now makes a transverse cut through the anterior wall of the 
vagina into the bladder, introduces the forceps, and extracts the calculus. 
The size of the opening must be determined by the magnitude of the stone. 
An incision one inch in length will be ample for the removal of a calculus 
the diameter of which is two inches. After the concretion has been extracted, 
the wound must be closed by the wire and shot suture, and a catheter worn 
from twelve to fourteen days. In other words, the case must be managed 
in all respects like one of vesico-vaginal fistula. The operation is attended 
with little danger to life. In 113 cases, which include 35 by Aveling, 30 by 
Vidal, and 48 by different American operators, there were 3 deaths. One of 
these deaths occurred in a patient under the care of Dr. Brinton, when the 
stone was so large as to necessitate the use of a drill attached to a dental 
engine before it could be removed.f In another fatal case, under the care of 
Dr. Fowler,J the calculus weighed eight ounces. As the earlier operations 
of this kind were done before the improvements by Dr. Sims in the branch 
of gynajcological surgery were known, it is reasonable to infer that the large 
proportion of calculous patients so treated were left with vesico-vaginal 
fistula. 
The supra-pubic operation, opening the bladder in the female above the pubes 
for the removal of a calculus, does not in any way differ from the same oper- 
ation in the male. 
Of 82 cases of this operation in females, 72 recovered, and 10 died, or 12.19 
per cent. 
* Transactions of the Obstetrical Society, vol. i. p. 1864. 
f American Journal of the Medical Sciences, 1878, vol. e. p. 757. 
j Medical and Surgical Reporter, 1878, vol. xxxviii. p. 500. 696 
INJURIES AND DISEASES OF THE GEN1TO-URINARY ORGANS. 
The mortality is less in females than in males; 383 operations done in the 
latter gave 258 recoveries and 125 deaths,-a mortality of 32.63 per cent. 
The subject of stone in the female may be summarized thus: 
1st. When the stone does not exceed one inch in diameter and has a rea- 
sonably regular surface, the proper course to be adopted is rapid dilatation of 
the urethra and extraction by the forceps. 
2d. When the calculus exceeds the above-stated dimensions and is not too 
hard to be broken by the lithotrite, it should be crushed, and at the same time 
removed by the forceps and by aspiration. 
3d. When too hard and too large to be thus dealt with, the stone should 
be extracted by opening the vesico-vaginal septum, breaking the concretion, 
if necessary, before extracting it. 
4th. Lateral lithotomy should not be practiced when the stone can be 
extracted either by dilatation or by the vaginal incision. 
5th. Supra-pubic lithotomy should not be resorted to unless under circum- 
stances in which the other operations cannot be performed. 
DISEASES OF THE KIDNEYS AND URETERS. 
Anomalies.-The kidneys present various deviations from the normal 
standard. These include the form, position, and number of the glands. 
Deviations in form are generally associated with those of position. Thus, 
in displaced kidney the shape is round, quadrangular, or preternaturally 
flattened. Occasionally the organ appears to be arrested in its development, 
not passing beyond the lobulated state. The unusual positions taken by the 
kidney are in front of the vertebral column, above the spleen, or even in 
the pelvis. Hohl reports a case in which, in consequence of the organ being 
situated in the last-named position in a parturient female, the delivery of 
the child was greatly delayed. The kidney could be recognized through the 
walls of the vagina. Forty years after, a post-mortem examination verified 
the abnormity. Not unfrequently there exists but a single kidney, and this 
may occupy the proper position, or it may rest across the spine. When soli- 
tary, the size of the organ exceeds considerably that of the normal kidney; 
it has generally two ureters. The two glands are occasionally found united at 
their lower (more rarely, at their upper) extremities, forming the horseshoe 
kidney, and resting in front of the vertebral column. 
These anomalies of position appear to affect the left more than the right 
kidney, and men oftener than women. Weisbach has collected 44 eases of 
malplaced renal organs, 35 of which concerned the left organ, 8 the right, 
and in 1 both were displaced. In 29 cases, 20 were men and 9 were women; 
and of a like number of solitary kidneys collected by Roberts, 22 were males 
and 6 females, and in 1 the sex was not marked. 
Generally these abnormities are attended with so little inconvenience as 
rarely to be detected during life; in illustration of which fact not one of the 
48 cases collected by Stern appears to have been recognized before death. 
Sometimes, however, serious evils may follow the irregularity. Of this nature 
was the case reported by Neufritle,* in which, by the pressure of a horse- 
shoe kidney on the vena cava, thrombosis of the veins below was produced, 
and death resulted from interruption to the venous circulation. Koster gives 
an instance of a woman who died during pregnancy from the effects of the 
gravid uterus pressing on a large horseshoe kidney. 
When only one kidney is present, the organ is predisposed to disease, in 
consequence, no doubt, of the work which it is compelled to perform. 
Floating or Movable Kidneys are frequently observed. The condition is 
either congenital or acquired, and in almost all cases is met with in females. 
The right kidney is generally the one affected. Of 96 cases compiled by 
Ebstein, 82 occurred in females and 14 in males. Of 5 cases which have 
* Ziemssen's Cyclopedia of Practical Medicine, vol. xv. p. 771. FLOATING AND MOVABLE KIDNEYS. 
697 
come under my own notice, 4 were females and 1 was male. When acquired, 
the displacement will be likely to happen in the period between thirty and 
forty years of age, and in persons who are not obese. 
Causes.-The causes which are concerned in producing the floating kidney 
are tumors, which, being developed in close proximity, finally encroach upon 
the renal organs and thrust them from their normal habitat. Disease of the 
kidneys themselves, as cancer or hydronephrosis, tends also to cause their 
displacement. The disappearance of the fat in which the organs are im- 
bedded, or looseness of the surrounding connective tissue, also predisposes 
them to a change of place. Perhaps the most influential of all causes in 
determining the displacement is violent muscular exertion ; and this is 
rendered more probable by the fact that the floating kidney occurs generally 
among individuals who belong more particularly to the working-classes: 
in some cases there seems to be a deficiency in extrinsic pressure, owing 
to the abdominal walls having been somewhat weakened by a succession of 
pregnancies. 
Symptoms.-Persons who are the subjects of floating kidneys have very 
different experiences. In some the displacement creates so little discomfort 
as scarcely to be recognized, and is only discovered accidentally. In other 
instances the uneasiness is quite considerable, and can be traced to a par- 
ticular moment when, on making some unusual exertion, something has been 
felt to leave its usual position and rise to the front of the abdominal cavity; the 
mobility and weight of the kidney, and the tension of the renal nerves, give 
rise to fixed or radiating pain, a dragging sensation, and nausea, all of which 
are aggravated by active movements. Sometimes paroxysms of intense suf- 
fering occur, preceded by rigors and faintness, which arc supposed by Gilew'ski 
to be due to a form of strangulation caused by a twist in the ureter and the 
vessels of the organ. A careful manual exploration, particularly in patients 
who are thin, will result in the discovery of a movable tumor near the um- 
bilicus or right hypochondriac region, which in some cases can be recognized 
as the kidney by its peculiar outline, and possibly by the detection of pulsa- 
tion in the vessels occupying the hilus of the organ. In connection with these 
phenomena the lumbar region will exhibit signs of the kidney having left its 
natural position, being somewhat sunken in, and yielding, when percussed, a 
resonant in place of the ordinary flat sound. 
Prognosis.-Though a tumor of this character becomes the source of much 
mental disquietude, as well as physical suffering, I am not aware that the 
movable kidney ever causes death. It may be reduced, or it may contract 
adhesions to other of the neighboring viscera, and in this -way become more 
stationary. 
Treatment.-In all cases where the diagnosis has been satisfactorily es- 
tablished, an attempt should be made to restore the kidney to its proper place. 
To this end, the patient should lie upon his back, with the limbs drawn up and 
the body bent forward, while the hand of the surgeon presses the organ 
directly back toward the lumbar region. Should the manipulation prove 
successful, and the enlargement disappear, a broad compress at least three- 
quarters of an inch in thickness must be secured to the inner surface of an 
elastic and accurately-fitting abdominal bandage, which is to be worn around 
the body. The patient must avoid all violent muscular exertion. No corsets 
should be worn, nor must the bowels be allowed to become constipated, as all 
straining efforts conduce to a return of the displacement. 
In the event of sudden attacks of pain, with nausea, abdominal tenderness, 
and other signs of strangulation, it will be necessary to confine the patient 
to the recumbent position, apply hot fomentations over the abdomen, and 
administer anodynes, either by the rectum or hypodermically, when the 
reduction may be attempted with a fair prospect of success. 
If the displaced organ cannot be replaced, and the abdominal symptoms 
culminate in a local peritonitis, it will be best to desist from attempts to 
restore the gland to its proper place, and to adopt such measures as are cal- 698 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
culated to subdue the inflammation of the peritoneum, as the use of leeches, 
opium, and hot cataplasms. When this is accomplished, a second and per- 
haps more successful attempt at reduction may be made. 
Should these incarcerations of the kidney frequently occur, threatening 
as they do the life of the patient, and the gland fail to contract some fixed 
moorings, there will naturally occur to the surgeon the question of nephrot- 
omy,-an operation which, except under the most urgent circumstances, 
ought not to be performed. 
Nephritis. 
Inflammation of the kidney, as it is witnessed by the surgeon, partakes 
more of the chronic than of the acute form. 
Acute Nephritis.-The causes concerned in developing that form of nephritis 
which comes properly within the domain of surgery are rarely of idiopathic 
origin, and I do not propose to treat of Bright's disease, or of desquamative 
or interstitial nephritis. 
Nephritis may follow traumatic causes, as wounds, contusions, strains, and 
operations on the urethra and bladder, or may result from an irritation or 
inflammation propagated from portions of the urinary passages more or less 
remote from the kidney, as in stricture or cystitis, also from the mechanical 
irritation of renal calculus. Even inflammatory affections of structures which 
have no other relation to the kidneys than that of contiguity, as disease of 
the vertebrae, psoas abscess, and hepatic disorders, will extend to the renal 
organs and cause their inflammation. To these causes may be added cold, 
a gouty or rheumatic state of the system, and that kind of irritation which 
results from the operation of medicinal agents which have a tendency to pass 
through the kidneys, as cantharides, the turpentines, and alcohol. 
The seat of the inflammation may be either that part of the organ which is 
concerned in the secretion of the urine, constituting true nephritis, or those 
parts which act as receptacles for the urine, as the calices, infundibula, or 
pelvis. 
Symptoms.-The attack is ushered in generally by a chill, followed by pain 
in the loins, nausea, and vomiting. The pain is usually dull, deep-seated, 
sometimes lancinating, extending down the thigh, along the ureter or the 
spermatic cord, attended by retraction of the testicle, is aggravated by 
pressure, by turning in bed, or by coughing, and is always greater when the 
patient is standing or sitting than when he is in the recumbent position. 
The bladder becomes irritable, and there is frequent micturition of scanty, 
high-colored urine, containing blood, and finally pus. The reaction of the 
urine is sometimes alkaline, and at other times neutral, and the albumen 
(which, on the application of heat, is seen to exist, and which appears after 
the blood) is to be referred to the presence of the latter fluid. With the 
microscope renal casts can be detected, which contain both blood- and pus- 
corpuscles. The general system quickly sympathizes with the local inflam- 
mation, giving rise to an accelerated circulation, increased temperature, dry 
tongue, thirst, headache, and nervous restlessness. 
Treatment.-One of the earliest and most. important measures in the 
treatment of acute nephritis is to secure a free action of the bowels, by 
administering a few grains of calomel, followed by citrate of magnesia or 
sulphate of soda. When the pain is severe, wet cups should be applied over 
the lumbar region, followed by large, hot, emollient poultices. Often a hot 
bath will give great relief. The use of diuretics is to be avoided. It is just 
as important to secure rest to the kidneys wThen inflamed as to an intestine 
in a similar state: hence liquids are to be used in moderation. The skin 
must be called to a vicarious office in order to perform the work which it is 
the special province of the kidneys to do in health. Hence diaphoretics, as 
Dover's powder, must be given. Should the vomiting prove obstinate, the 
effervescing draught or carbolic acid water will prove useful. To relieve PYELITIS. 
headache, counter-irritation by mustard sinapisms should be made over the 
nape of the neck, the epigastric region, on the calves of the legs, and on the 
ankles. The use of the catheter, unless positively demanded by a distended 
bladder, is to be carefully avoided, as any irritation of the urinary passages 
will react injuriously on the renal organs. When acute nephritis has a gouty 
or a rheumatic origin, the use of iodide of potassium and colchicum will be 
required, in addition to the remedies already indicated. 
699 
Chronic Nephritis may follow the acute form of the disease, or it may 
begin in so quiet a manner from obstructive causes, as stricture, enlarged 
prostate, or disease of the bladder, as scarcely to be suspected. It also not 
unfrequently follows prolonged suppuration, such as occurs in necrosis. The 
symptoms are quite unlike those -which characterize the acute form of the 
disease. There is no inaugurating chill or rigor, no retraction of the testicles, 
no acute pain radiating along the cord or down the thighs. The bladder, 
however, is irritable, requiring to be frequently emptied. The urine is turbid, 
albuminous, loaded with amraoniaco-magnesian phosphates, alkaline in its 
reaction, and contains blood, pus, and renal casts. The general health is 
gradually undermined, the patient losing his appetite, flesh, and strength. 
These symptoms finally culminate in an irritative or hectic fever, which grad- 
ually wears the sufferer out, or the disease may have a more sudden termi- 
nation by the supervention of complete suppression of the urine, headache, 
convulsions, coma, and death. The existence of chronic nephritis greatly 
enhances the danger attending an operation, and hence the importance of 
examining the urine previous to undertaking any case requiring the use of 
the knife. 
Treatment.-The treatment of chronic nephritis is conducted with a view 
to retard the disease and to palliate the symptoms. A cure is not to be 
looked for. The body is to be carefully protected against Cold. The glandular 
apparatus of the skin is to be preserved in a moderately active state by warm 
baths and clothing, the bowels kept in a soluble condition, the quantity of 
animal food taken by the patient restricted, moderate exercise allowed, all 
stimulants avoided, and mineral tonics, as the tincture of the chloride of iron, 
exhibited, with a view to improve the blood and counteract the effects of the 
imperfectly-performed functions of the renal organs. 
Both acute and chronic nephritis are prone to terminate in suppuration. 
Pyelitis.-In pyelitis the inflammation which precedes the formation of pus 
is chiefly confined to the pelvis, infundibula, and calices of the kidney. It 
rarely exists in the acute form. 
Causes.-These can generally be referred either to those obstructions which 
interfere with the free passage of the urine, as stricture, hypertrophy of the 
prostate, and chronic cystitis, or to the presence of renal calculus. In one 
case reported by Mosier, in a boy of eighteen years, the obstruction resulted 
from a neglected phimosis. It is occasionally met with as a sequel of certain 
of the exanthemata, as scarlatina and smallpox. It may follow pyaemia, 
hydatids, cancer, and even irritating diuretics. 
In the obstructive variety, the mucous membrane of the urinary passages 
is, in consequence of the backward pressure of the urine, kept in a dilated, 
congested state, which condition, if long maintained, terminates in an in- 
flammation that gradually creeps upward along the ureters to the pelvis 
of the kidney. Renal calculus constitutes perhaps the most common cause 
of pyelitis. Ollivier speaks of blood-clots in the pelvis causing this condition. 
A concretion once formed in the kidney cannot long exist without pro- 
voking inflammation of the lining membrane of the pelvis or its subdivisions. 
Even if the stone leaves the kidney and becomes arrested in the ureter, if it 
is long delayed in this duct pyelitis will be likely to follow, as two potent 
causes of the disease are in operation at the same time, namely, obstructive 
and mechanical irritation. Nor is the disease limited to the pelvis. If the 700 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
exciting cause is not removed within a reasonable length of time, the inflam- 
mation extends by continuity of tissue to the parenchyma of the kidney, and 
the organ becomes the subject of both pyelitis and nephritis. . 
Symptoms.-An early and prominent symptom of pyelitis is pain in the 
back. This is particularly severe if the disease depends on the presence of 
stone. This pain radiates along the ureter towards the bladder, down the 
inner aspect of the thigh, is felt in the groin, and extends along the course of 
the spermatic cord to the testicle, causing the retraction of the latter. Ten- 
derness is experienced when pressure is made over the renal region. Attempts 
have been made to distinguish calculous pyelitis from that arising from other 
causes, on the ground that in the former there has been an antecedent history 
of occasional attacks of nephritic colic; but this is a very deceptive test, as 
the last-named symptom may exist independently of stone. Frequent calls 
to micturate are also among the early signs of the disease, and may be so 
marked a feature that the attention of the physician is directed exclusively 
to the bladder. The urine is acid and at first scanty ; later it becomes more 
abundant. A microscopic examination of the secretion reveals blood-corpuscles, 
mucus, and an abundance of renal epithelium of different forms, and, as the 
affection advances, pus appears disseminated through the urine, imparting to 
it a hazy or turbid appearance. 
As the disease progresses, the patient emaciates, loses strength, and dies, 
worn out by hectic, or it may be in a sudden convulsion provoked by the 
accumulation of urea in the blood. 
Prognosis.-The prognosis in a case of pyelitis will depend in a great 
measure on the character and duration of the cause which produces it, and 
on the single or double form of the disease. If it follows a case of stricture, 
the removal of the latter, so as to allow an unobstructed flow to the urine, 
will tend to arrest the disease, and may be followed by recovery. If in- 
duced by the irritation of a renal concretion, and the stone is not too large 
to reach the bladder, its escape will form a reasonable ground for believing 
that the pyelitis will subside. That form of the affection which occurs as a 
concomitant of certain exanthemata, of pleurisy, or of scurvy, will disappear 
with the morbid affections which brought the disease into existence. If asso- 
ciated with pyaemia, carbuncle, cancer, tubercle, chronic cystitis, or enlarged 
prostate, no hope of recovery can be entertained. When pyelitis is double, 
or affects both kidneys, a fatal termination may be expected. 
Treatment.-This must be determined by the cause. If stricture of the 
urethra exists, it must be immediately dilated. If cystitis is present, as also 
in cases of prostatic hypertrophy, attention must be given to the removal 
of all residual water. 
When the pyelitis is connected with zymotic disease, the kidney difficulty 
is best treated by attention to its antecedent; and the same is true with 
regard to all those affections which are instrumental in occasioning the dis- 
ease. When there is reasonable certainty that the pyelitis has a calculous 
origin, our hope of affording relief must rest on the use of those agents 
which possess some solvent power over the stone. When the calculus is 
composed of uric acid, which may be recognized from the character of the 
urinary deposit, and which is the most common constituent of calculi, some 
benefit may be expected from the protracted employment of bicarbonate 
of potash largely diluted, and used to the extent of forty or sixty grains a 
day. It is within the range of probability that a sufficient amount of the 
calculus will be dissolved to allow of its escape by the natural passages. Even 
its complete solution has, it is believed, occurred. 
Pyelitis may in its course become acute; in which case the pain is intensi- 
fied, the thirst great, micturition frequent, and blood and pus appear in abun- 
dance in the urine. Under such circumstances the treatment will be almost the 
same as in acute nephritis,-cupping over the loins, hot hip-baths, and warm 
poultices over the lumbar region, with Dover's powder to alleviate pain and 
favor the free action of the skin. Alkaline diluents may be allowed in modera- PERINEPHRITIC ABSCESS. 
701 
tion. In case the flow of blood becomes too great, ergot, gallic acid, and 
opium should be administered. The liquor ferri pernitratis will also be found 
to exert a controlling influence over renal hemorrhage. In all cases of pye- 
litis it will be necessary to direct the patient to keep the body well clothed, 
to avoid exposure in cold, damp weather, to avoid all alcoholic beverages, 
to use milk largely as an article of diet, and to keep up the tone of the system 
by the use of the tincture of the chloride of iron, occasionally combining it 
with some vegetable tonic. 
Abscess and sacculation of the kidney are frequent results of both pyelitis 
and nephritis. The sacculation may be suspected when the discharge of pus 
is intermittent, diminishing for a time as it collects in one of the pouches, 
and then overflowing and appearing in large quantities in the urine, forming 
a dense and light-greenish deposit at the bottom of the vessel. 
Suppuration is announced by the development of rigors, followed by fever 
and sweating, which not uncommonly appear with a regularity similar to 
that of an intermittent, the exacerbation occurring towards evening. As the 
disease progresses, the entire organ may become dilated into a number of 
Fig. 1425. 
Sacculated kidney, the pouches containing'numerous calculi. 
pouches often filled with calculi, and obliterating all traces of the secretory 
structure of the kidney. (Fig. 1425.) 
Abscess of the Kidney (Pyonephrosis) may be situated in the pelvis of the 
organ, in its glandular structure, between the lattei' and the fibrous capsule 
which incloses the gland, or even entirely external to the organ, in the loose 
fatty and cellular tissue which surrounds it. 
Renal abscess is not always produced by previous disease of the kidney. 
It may follow injury and disease of the vertebrae and of the spinal marrow. 
The knife of the pathologist constantly discloses deposits of purulent matter 
in the kidneys after death from pyaemia. Disseminated or diffused abscesses 
occur in the kidney from obstructive causes, forcing the urine back into the 
tubuli recti of the Malpighian cones. The pus is found along the course 
of the interlobular veins. The return of urine loaded with poisonous prod- 
ucts into the vessels occasions the formation of emboli, which, extending into 
the adjoining vessels, not only lay the foundation of multiple abscesses in the 
kidney, but are capable of developing a general infection, or pyaemic state of 
the system at large, but without the participation of other organs in the 
suppuration. The condition has been particularly investigated by Dr. Dick- 
inson, is sometimes described as the " surgical kidney," and is a very common 
cause of death after operations on the urinary passages. 
Perinephritic Abscess, which includes abscess both in the fibrous capsule 
of the gland and in the loose ccllulo-adipose tissue in which the kidneys are 702 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
imbedded, may arise as a consequence of previous kidney disease, from caries 
of the adjoining vertebra?, from violent sprains or twists of the lumbar 
muscles, and from disease of the testicle or the cord, the irritation being 
propagated to the peri-renal connective tissue. This affection, first lucidly 
described by Bayer, has been carefully studied by Trousseau in his medical 
clinic, by Feron, Gibney, and Professor Bowditch. Duffin* has analyzed 26 
cases of the disease. The three cases published by the last-named surgeon, 
and believed to be altogether independent of kidney disease, are exceedingly 
instructive, not only as to extension of the purulent collection, but also as to 
the necessity of an early opening being made for its evacuation. In all of 
them the pus had followed the sheath of the psoas muscle, passing beneath 
one of the arctuated ligaments of the diaphragm, exciting pleurisy, and, 
after opening into the bronchial air-passages of the lung, was expectorated 
by the mouth. Similar cases have been reported by Bayer and Lennesrew.f 
The other directions which abscesses of this nature may take are into the 
colon or the bladder (GintracJ gives an instance of the former), or between 
the erector spina? and the abdominal muscles over the lumbar region, in the 
position of lumbar hernia, or along the psoas and beneath Poupart's liga- 
ment to the front of the thigh, or into the pelvis. 
Symptoms.-Both renal and perinephritic abscesses arc attended with local 
and constitutional symptoms. At first there is usually experienced in the 
loin corresponding to the affected organ some uneasiness, w'hich finally cul- 
minates in lumbar pain, aggravated on pressure, straining, coughing, turning 
in bed, or standing. The pain extends along the spermatic cord towards the 
sacrum, and is often felt in the groin. There is also an acceleration of the 
circulation, with an elevated temperature, considerable thirst, frequent mictu- 
rition, and more or less nausea. With the formation of pus are developed 
rigors, heat, and sweating. If the purulent collection is situated in the kidney, 
it will probably open into the pelvis, the pus appearing in the urine,-a fact 
which is calculated to throw much light on the nature of the case. In renal 
and particularly in perinephritic abscess a distinct and sensitive swelling or 
tumor will be found in the loin, with oedema of the skin, and probably an 
emphysematous state of the cellular tissue of the back. This was the con- 
dition in two of Trousseau's cases. When the pus tends towards the surface 
of the lumbar region, flexion of the thigh and the common characteristics 
of deep-seated abscesses-oedema and redness-will be present. 
Diagnosis.-More or less uncertainty must necessarily attend the diagnosis 
of perinephritic abscess. The diseases with which it may be confounded 
are lumbar neuralgia and rheumatism, pyelitis, hydronephrosis, cancer, psoas 
abscess, and lumbar hernia. Neuralgia, however, and rheumatism of the 
lumbar muscles are not accompanied with chills, fever, or a high tempera- 
ture, nor is there in these diseases any enlargement or swelling in the loin. 
To distinguish perinephritic abscess from pyelitis will be a matter of the 
greatest difficulty. The presence of purulent urine and the absence of lumbar 
oedema, characteristics of the first-named disease, will form grounds for 
drawing the distinction. In hydronephrosis, though a tumor may form in 
the loin, it is painless, while the lumbar swelling in perinephritis is sensitive. 
Carcinomatous tumors of the kidney are not usually attended with febrile 
symptoms, a fact which may aid in their differentiation from perinephritic 
abscess. 
Though in both perinephritis and psoas abscess there are flexion of the 
thigh and lumbar uneasiness, it will be found that in the former extension of 
the limb creates no uneasiness, and does not produce any incurvation of the 
lumbar spine. This is not the case in the latter affection. The lumbar ten- 
derness on pressure in perinephritis is also absent in psoas abscess. Lumbar 
hernia, though exceedingly rare, will, when present, form a tumor over the 
* Medical Times and Gazette, 1872, vol. ii. 
t Sur ]es Fistules Reno-pulmonaires, de Paris, 1840 : Ziemssen. 
J L'Union MSdicale, 1867, No. 48: Ziemssen. HYDRONEPHROSIS. 
703 
loin which might be mistaken for a perinephritic abscess. Petit alludes to a 
case of the kind, the true nature of which, however, was established by its 
reducibility. 
In neuralgia, the accession of the pain is sudden, intermittent, and not 
aggravated by pressure (characteristics the reverse of those belonging to 
perinephritis). 
The differential diagnosis between purulent pyelitis and perinephritis is 
predicated on the heavy deposits of pus in the urine, and on the subjective 
nature of the lumbar symptoms, peculiarities which belong to the former. 
Treatment.-During the early or acute stage of the nephritis or cellulitis 
which must necessarily precede the formation of abscess, the treatment will 
not differ from that described under the head of inflammation of the kidney, 
namely, cupping, purging, hot hip-baths, and diaphoretics with anodynes, 
with rest in the recumbent position. When the swelling becomes visible in 
the loin or elsewhere, it will be proper to make an early evacuation of its 
contents. By an opening in the loin the kidney may be reached without ex- 
posing the peritoneum. For this purpose the aspirating trocar can be used 
with the greatest advantage, or, in the absence of this instrument, the tis- 
sues should be divided cautiously, in the order of superposition, on a director, 
until the abscess is nearly reached, when the remaining layer of structure 
may be punctured, and afterwards the opening freely enlarged, that the pus 
may escape without obstruction. If the abscess is perinephritic, the prog- 
nosis will not be unfavorable. When it is nephritic or pyonephritic, the 
prospect of recovery will be very uncertain. When it opens on the surface 
of the body, a renal fistula may be anticipated. 
Mr. Jessup, in order to prevent the pus from passing into the bladder in 
a case of suppurating kidney, exposed the diseased organ through the back 
and inserted a drainage-tube, to the great relief of his patient. Lente, in 
a similar manner, succeeded in effecting a cure of a nephritic abscess. 
Nephrotomy has also been performed for the cure of the disease. (See 
-Nephrotomy.') 
Hydronephrosis.-This disease, the hydrops rendlis of Walter, was very 
accurately described by him at the beginning of the present century. It con- 
sists in an expansion of the pelvis and the ureter in consequence of an 
obstruction to the escape of the urine at some point in the course of the 
urinary tract. 
This condition is sometimes congenital, and when so is often found asso- 
ciated with other vices of development, as hare-lip, club-foot, etc. Several 
cases of the kind have been noticed by Dr. G-ervis before the London Ob- 
stetrical Society. Foetal hydronephrosis may attain such dimensions as to 
interfere seriously with delivery. The extent to which the dilatation takes 
place will depend on the position of the obstruction. The lower down it is, 
the more will the ureter participate in the disease. 
Among the acquired causes may be enumerated calculous concretions which 
become impacted in the ureter; inflammatory narrowing of some part of the 
ureter; pressure from a displaced retroflexed uterus; malignant and other 
tumors in the pelvis and the abdomen; abscess and morbid growths which 
encroach on the openings of the ureters; and anomalous emulgent arteries. 
Hydronephrosis when existing to any great degree is destructive to the 
kidney. Under the force of the fluid the dilated pelvis, infundibula, and 
calices of the gland become misshapen and wasted, following which the 
external part of the organ is destroyed, until finally there remains only an 
enormously dilated lobulated sac, which may fill the abdomen and extend 
into the pelvis, contracting in some instances extensive adhesions to the 
surrounding viscera. In two cases of the disease which I saw, the sac pushed 
out the abdominal walls immediately below the cartilages of the ribs on the 
right side, and turned up in front of the corresponding side of the thorax. 
When the obstruction is low, the ureter may become expanded until its 704 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
circumference measures three inches. The contents of the sac consist of 
imperfect urine, or a watery fluid in which uric acid, urates, and oxalate of 
lime are present. The fluid may be reddish, brown, yellow, or turbid, and 
contains muco-pus. Its reaction is usually alkaline. In a few instances a 
fatty matter has been seen in the sac, also colloid substances. Though in 
general hydronephrosis affects only one kidney,-the other becoming hy- 
pertrophied,-both organs are occasionally involved. 
Symptoms.-The early signs of hydronephrosis are so similar in their char- 
acter to those of many other disturbances of the urinary organs that they 
possess no diagnostic value. Indeed, when only one kidney is affected, and 
to a moderate degree, nothing unusual may be observed either by patient 
or by physician. 
When both organs are implicated,-an unusual event,-the embarrass- 
ment in the flow of urine will soon attract attention. Not only will the 
secretion be discharged in small quantities into the bladder, but occasionally 
when some temporary swelling of the ureter occurs it will be all retained for 
a time in the dilated chambers of the kidney, or until the pressure resulting 
from the accumulation is sufficient to force the obstruction to its passage, 
when it may again suddenly enter the bladder in considerable quantities. 
Urinary incontinence, vomiting, and a sallow and anxious appearance of the 
face are common attendants of the disease. It is only, however, when the 
distention has become of sufficient magnitude to form a considerable tumor 
that the case begins to assume such distinctness as to make its recognition 
probable. The swelling appears in the flank and lumbar region, extending 
forward in an antero-lateral direction. It is fixed and painless, soft and fluc- 
tuating to pressure, somewhat irregular or lobulated in its outline, and yields 
a flat percussion sound. When the obstruction to the passage of the urine 
is temporarily removed, as when an impacted calculus passes from the ureter 
into the bladder, the tumor undergoes a sudden diminution in size, enlarging 
again when another concretion takes the place of the first, as occasionally 
occurs. The quantity of fluid which one of these sacs contains is some- 
times very great. Baum, of Gottingen, reported a case in which there were 
twenty-five pints present, and Spencer Wells one in which sixteen pints were 
found. 
Prognosis.-Slight cases of hydronephrosis, caused by a temporary delay 
of a renal calculus in the ureter, terminate favorably. The patient may sur- 
vive a long time when the disease is unilateral, the sound kidney being capable 
of performing a compensatory work for the disabled one. In extreme cases 
of hydronephrosis, affecting either one or both organs, the patient soon dies 
in a state of stupor or in convulsions from ursemic poisoning, the parenchyma 
of the kidney being destroyed. In a case which I witnessed, and which ter- 
minated fatally, there was a congenital absence of one kidney, the existing 
one being placed in the median line across the vertebral column. 
Diagnosis.-Hydronephrosis resembles in some of its aspects abdominal 
dropsy, ovarian and hydatid cysts, and suppurative nephritis. 
In abdominal dropsy the swelling is not confined to one region, but changes 
its position with that of the patient. Hydronephrosis is local; position has 
no effect in changing the situation of the tumor, the loin answering to the 
swelling remaining flat on percussion, even though the patient turns on the 
opposite side. 
The signs of ovarian and renal cysts are so similar that the distinction 
is not easily drawn from the rational signs alone. In general it may be 
said as a basis for the differentiation of the two affections that ovarian tumors 
are very common as compared with hydronephrosis, and that in cases of 
the former disease there is generally a steady emaciation in progress. The 
exploring or the aspirating needle will offer the readiest solution of the diag- 
nostic problem, as the sac of hydronephrosis never contains the thick, ropy 
fluid of an ovarian cyst, nor does the latter ever yield a fluid resembling in 
its composition the urine. RENAL CALCULUS. 
705 
In cysts of a hydatid origin there is usually a discharge of hydatids with the 
urine, which will reveal the nature of the malady. 
In suppurative nephritis, or pyonephritis, in addition to the presence of 
pus in the urine, there will be found to have been an antecedent history of 
chills, fever, and sweating,-phenomena which do not necessarily belong to 
hydronephrosis. 
Treatment.-Little is to be expected from therapeutics in hydronephrosis. 
If the disease is the effect of nephrolithiasis blocking up or obstructing the 
canal of the ureter, the solvent property of the alkaline remedies will be 
worth a trial. Kneading or pressure of the tumor with a view to dislodge 
any obstructing body, as a calculous concretion, has been successfully em- 
ployed by Roberts in the case of a girl eight years old. Thompson, Hillier, 
and Fraenkel have tapped these swellings with apparently some advan- 
tage ; but any operation of this nature should be reserved for cases in which 
the life of the patient is threatened by the pressure of surrounding organs, 
as in oedema of the lungs. When there is from this cause an urgent need 
for operative interference, the aspirating trocar will be the proper instru- 
ment, and the point at which it should be introduced into the tumor is in the 
lumbar region, on the outer edge of the erector spinse muscle, and close to 
the border of the last rib. By this course the sac is entered behind the peri- 
toneum. When the tumor bulges in front, of course this rule cannot be 
adhered to, and the puncture must be made where the prominence is most 
marked. In addition to puncture, attempts have been made to obliterate the 
sac by injections of iodine. This was done, it is said, successfully by Billroth 
and by Schrbtter. Maas, following in the lead of Simon, used a double punc- 
ture with two trocars, allowing the canulae with closed stop-cocks to remain; 
these were removed on the fourth day, after laying open the walls of the 
abdomen and the sac between; drainage-tubes and carbolic acid dressings 
were subsequently employed. Death followed, however, a few days after the 
operation. Last among the measures adopted for the cure of hydrone- 
phrosis is nephrotomy, which was performed in one case by Nicaise and 
Meadows. 
Renal Calculus. 
Should the saline substances which in a normal condition of the urine are 
held in a state of solution be precipitated in the form of crystals, there arises 
a condition which is commonly known as gravel. 
The formation of gravel or sand is the initial step in the production of 
stone in the kidney. The aggregation of a few crystals cemented together 
by a little mucus, or the lesion of a few capillaries by the grit, giving rise to 
a little clot of blood, constitutes the nucleus for a concretion, which subse- 
quently may be swept into the ureter and excite an attack of nephritic colic, 
or may be detained in the kidney and by continued accretion attain a bulk 
which will render its passage to the bladder impossible. 
Griesinger states that in Egypt he has seen the eggs of the distoma haema- 
tobium constitute the nucleus for the formation of kidney stone. 
These calculi form in different portions of the renal organs,-in the cali- 
ces, infundibula, pelvis, and even in the straight uriniferous tubes and in the 
parenchyma. 
The concretions may be either single or multiple. In some instances hun- 
dreds are observed scattered through the organ, and they vary in size from 
that of a mustard-seed to that of a walnut. Numerous cases have been 
reported where the calculus filled the entire pelvis, infundibula, and calices 
of the kidney. Their surface presents a great variety of appearances. Some- 
times they are smooth; sometimes they have facets, the result of friction 
between one or more concretions; at other times they are rough and tuber- 
culated. 
Renal calculi are generally composed of uric acid or of oxalate of lime, most 
commonly the former. When the concretion is an oxalate, it is usually 
vol. ii.-45 706 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
solitary, and may have a nucleus consisting of uric acid. Ammoniaco-mag- 
nesian concretions are not often seen in the kidney as a primary deposition; 
and the same may be said of phosphatic calculi. 
Eenal calculi are quite common in childhood. They are met with in the 
foetal kidney. Between the ages of fifteen and thirty-five years the tendency 
to these concretions is markedly decreased; but it recurs after the latter 
period, and is frequently witnessed in persons of advanced life. Children 
who suffer from this affection belong, as has been noticed when treating of 
vesical calculus, to the poorer class of society; but in adults the reverse is 
true, these concretions being very generally observed among persons of sed- 
entary habits and given to free indulgence both in food and in drink. 
The effects of renal concretions on the structure of the kidney are determined 
by the size, form, character of surface, composition, and age of the calculus. 
When small, they are likely to be carried into the ureter, and thence pass 
onward into the bladder, where they either remain, forming the foundation 
for vesical calculus, or, more fortunately, are expelled from the viscus during 
urination. Should these stones remain in the pelvis of the kidney, or in one 
of its compartments, they will eventually, by the addition of new deposits, 
attain a size so disproportionate to that of the ureter that their expulsion 
becomes impossible. Such a concretion, particularly when its surface is rough, 
acts as a local irritant to the mucous membrane lining the pelvis, giving rise 
first to an inflammatory redness, and even to multiple spots of ecchymosis. 
This is followed by a catarrhal state of the lining membrane, constituting 
pyelitis, in which there is poured into the pelvis of the gland first a mucous 
and later a muco-purulent material. Or the obstruction offered by the con- 
cretion to the escape of the urine may dam back the secretion until the dilata- 
tion of the pelvis, encroaching more and more on the renal parenchyma, results 
in its destruction, and in the conversion of the organ into a hydronephritic 
sac. Even in this extreme condition, where the obstruction has resulted 
from the impaction of a number of small calculi, the latter may separate and 
escape through the ureter, and the sacculations may contract to an insig- 
nificant size. 
In other instances the pyelitis is propagated to the renal tissue, and a sup- 
purative nephritis follows, which results in the destruction of the gland, leaving 
only the expanded and lobulated sac of the pelvis with its infundibula, and 
these containing numerous calculous concretions. 
During the progress of these extensive structural changes it will sometimes 
happen that the inflammation of the kidney extends to the surrounding 
parts, as into the loose cellulo-adipose tissue in which the organ is imbedded, 
giving rise to perinephritis and extra-renal abscess, into the cavity of which, 
in the event of the sac rupturing, the concretions may be poured, or an ad- 
hesion may take place between the kidney and the colon, and the contents 
of the sac find their way into the intestine through an ulcerated opening. 
Symptoms.-The symptoms which indicate the presence of stone in the 
kidney are sometimes of a character calculated to lead the physician into 
error, all the phenomena pointing to the bladder rather than to the kidney. 
Then, it must have been observed by every surgeon of extensive experience 
that renal concretions may exist for years without disclosing any charac- 
teristic signs. In typical cases of the disease, however, more or less uneasi- 
ness and pain are experienced in the lumbar region, particularly when the 
body has been subjected to any violent movements. The pain is somewhat 
peculiar, being at times dull, with a sense of weight or pressure deep in the 
loin, and in other instances severe, cutting, and radiating in different direc- 
tions along the spermatic cord, down the ureter, or down the thigh. Along 
with these symptoms the patient often experiences creeps or slight rigors, 
accompanied with a frequent desire to urinate, the urine being, perhaps, 
slightly bloody. 
When the concretion leaves the pelvis of the kidney and enters the ureter, 
there will be little difficulty in recognizing the true nature of the disease. RENAL COLIC. 
707 
The pain, if it previously existed in the back, is at once transferred to the 
ureters, the severity of which announces an attack of renal colic. 
Renal Colic comes on under various circumstances. It often follows some 
unusual and violent movements of the body, as running, jumping, or lifting 
heavy weights, or it may come on during paroxysms of coughing. In some 
cases none of these causes seem to be active, attacks coming on during 
complete repose. The pain which arises from the distention of the urinary 
tract behind the stone is not restricted to the loins, but shoots down the 
ureters along the cord to the testicles, accompanied by retraction of the 
latter, which, if the attack proves obstinate, often enlarge and become super- 
sensitive. It will radiate, indeed, in all directions, around the body to the 
diaphragm, towards the shoulders, and even down the inside of the arm. 
The limb on the affected side often becomes numb and stiff, nausea, retching, 
and vomiting follow, a profuse perspiration breaks out over the surface, the 
pulse quickens, and the agony sometimes becomes so great that the suf- 
ferer is seized with tremblings, and even with convulsions. Women have 
been known to abort during a paroxysm of kidney colic. During the attack 
the bladder becomes exceedingly irritable, and the urine is much diminished 
in quantity, and often expelled in drops, scalding the urethra as it passes, 
and mingled with blood, mucus, and pus. When the calculus affects only 
one of the ureters, the kidney on the other or sound side may become preter- 
naturally active and a copious flow of limpid water follow. It is a rare 
occurrence for calculi to engage at the same time in the ureters of the two 
sides; but the anomaly of a single ureter for both kidneys sometimes exists, 
and this has been blocked by a concretion, the effect of which was to pre- 
vent in a great measure the passage of any urine to the bladder. The 
duration of an attack of renal colic varies in different cases. It may not 
last over a few minutes, or it may continue with remissions and exacerba- 
tions of pain for several days. The sudden subsidence of pain announces 
the entrance of the concretion into the bladder; though I have no doubt 
that occasionally the attack terminates when the calculus has only entered 
the mouth of the ureter, by a retrograde movement of the concretion into the 
pelvis, effected through the contraction of the muscular fibres of the tube. 
Treatment.-The indications in a case of renal colic are the alleviation of 
pain and the relaxation of the tissues concerned in the passage of the stone. 
For these ends the surgeon must rely on the use of opiates and the hot hip- 
bath or general bath. The opiates may be used hypodermically or by the 
bowel, either as enemas or as suppositories, in combination with the extract 
of belladonna. When the paroxysms of pain are exceedingly severe, great 
relief may be obtained from the inhalation of ether. In order that the con- 
cretion may be hurried through the ureter more rapidly than would be 
effected by the peristalsis of its muscular walls, it has been advised to ad- 
minister largely diuretic remedies, in order to excite a free secretion of urine, 
which presses against the obstruction from behind. This practice is capable 
of serious abuse. It is quite proper to administer alkaline drinks, as solutions 
of citrate or bicarbonate of potash, but their administration should be only 
to the extent of moderately stimulating the action of the kidneys, so that the 
vis a tergo shall be exerted within the limits of safety. Kneading has also 
been practiced,-an experiment, to say the least, of doubtful propriety. A 
flexed position of the body and the limbs, by removing the tension of the 
ureter, is favorable to the progress of the stone. In prolonged cases of de- 
tained calculus, when the belly becomes distended and tender, threatening 
peritoneal trouble, wet cups can be applied over the loins with advantage. 
To prevent the recurrence of these attacks, a careful examination should 
be made into the composition of the concretion if it is passed from the bladder, 
or, if not, into the prevailing constitution of the urine, so that proper reme- 
dies may be administered, and the diet, habits of exercise, etc., regulated', as 
described under the head of urinary deposits.  INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
708 
Renal Hsematuria is generally the result of external injury, as severe blows, 
falls, or twists of the lumbar part of the body, or of the mechanical irritation 
of renal calculus. It may be caused by any inflammatory condition of the 
kidney; by morbid growths and parasites in the organ ; by the action of 
some poisons, as phosphorus and arsenic; or it may result from the effects of 
certain diseases on the blood, as smallpox, scurvy, scarlatina, and malarial 
and typhoid fever. Embolism of the renal vessels sometimes accompanies 
heart disease, a condition which will prove influential in determining hemor- 
rhage. In certain parts of South America renal hemorrhage is endemic, the 
result of parasitic irritation. 
It is often a matter of great difficulty to ascertain the source of blood 
which may appear in the urine. Sometimes the solution of the question is 
effected by the appearance of the coagula. Thus, when the bleeding is from 
the pelvis of the kidney, the clots may be moulded so as to assume the form 
of the calices. When the hemorrhage comes from the parenchyma of the 
organ, the coagulation takes place within the uriniferous tubes; and when 
these clots are discharged, they retain the form (cylindrical casts) of the 
canals from which they are expelled, and may readily be recognized with the 
microscope. Renal hemorrhage is rarely excessive, and is generally asso- 
ciated with a feeling of some weight, and, possibly, slight pain, in the lumbar 
region. Large coagula in the urine usually have their origin elsewhere than 
in the kidneys. 
Treatment.-The ascertaining of the cause of heematuria, and the removal 
of that cause when possible, are very important preliminaries to the suc- 
cessful treatment of the disease. This cause is often exceedingly obscure; 
and consequently much of our medication is empirical. There are, however, 
certain measures which are always appropriate, let the cause be what it may. 
The patient must be confined on his back. If there is lumbar pain, with a 
strong pulse, wet cupping over the loins will be demanded, to be followed by 
the use of astringents and sedatives, as gallic acid, acetate of lead with opium, 
fluid extract of ergot, aromatic sulphuric acid, and Rockbridge alum water. 
When the individual is pale, weak, or anaamic, pernitrate of iron, or tincture 
of the chloride of iron, will prove most useful. 
Renal Cysts of different kinds are occasionally met with in the kidneys. 
Some of these are congenital, others are acquired, and still others arise from 
parasitic irritation. It is not impossible that in some instances that form of 
cystic degeneration which appears in adult life may have begun before birth. 
These cysts vary in size from that of a mustard-seed to that of a pigeon's egg. 
They occur either solitary, scattered through the parenchyma of the gland, 
or collected into groups. Their walls are greatly attenuated, or they may 
even be destitute of walls, the connective tissue of the gland serving as such. 
They contain uric acid and carbonate of lime, with certain colloid substances, 
and occasionally cholesterin. They are probably due to dilatation of the 
uriniferous tubules, in consequence of obstruction. 
Another variety of these cysts is met with, which appears to occupy in 
the main the cortical portion of the kidney. They present a beaded ap- 
pearance, their walls are thicker than those of the cysts already described, 
and their origin may be traced both to the urinary tubules and to the Mal- 
pighian glomerules. The contents of these cysts are chiefly colloid and 
pigment matters. 
As evidence of the tubular origin of these, at least when they are con- 
genital, it may be mentioned that they are found in the foetus to contain the 
constituents of the urine. The initial step in their formation is regarded by 
Virchow as an inflammatory one, or a nephritis, while Koster believes the 
condition to be due to a defective development of the tubules: this latter 
view receives some support from the fact that in these congenital cysts there 
are often other imperfections of structure. In extreme cases of the con- 
genital form of the disease, the mechanical obstruction presented to the rapid PARASITIC RENAL DISEASE. 
709 
birth of the child is such as to cause death, and may necessitate the operation 
of embryotomy. 
Parasitic Renal Disease is quite uncommon. When present, the parasites 
occupy both the secretory and the conductory portion of the kidney, occa- 
sionally project from the surface of the organ beneath its capsule, and rarely 
affect simultaneously both glands. They differ both in size and in number, 
varying in size from a pin's head to a goose-egg, and in number from a single 
one to hundreds. There are three parasites which are found in the kidney: 
the echinococci, first thoroughly described by Bremser in 1819; the strongylus 
gigas, or palisade worm; and the distoma hcematobium of Bilharz. 
The echinococci are the most common of renal parasites, and are derived 
from the teenise of the dog. Though these cysts are occasionally seen in the 
human kidney in Great Britain, and on the continent, the disease is said 
to be most common in South Australia and in Iceland, a large number of the 
deaths occurring in the last-named place being referred to this cause. The 
frequency of the disease in these localities is attributable to the number of 
dogs and their close companionship with man. 
The period of life at which this parasitic disease is most common is between 
the twentieth and fiftieth years. The cysts appear as globular, fluctuating 
sacs, the contents of which consist of a gelatinous capsule formed of several 
hyaline laminae, concentrically arranged, which constitute the mother-vesicle 
of the parasite. In this capsule there is also a clear fluid, floating in which 
are numerous small vesicles, within which are others of two or three gener- 
ations. The parasite has a head similar to that of the tape-worm. 
Symptoms.-The only sign of the existence of a parasitic or hydatid cyst 
is the escape of the animal with the urine, which, should there be at the 
same time a lumbar swelling, would reveal the true nature of the disease. 
Importance has also been given to what is called the hydatid fremitus, par- 
ticularly noticed by Piorry and by Brianacon, which derives its name from a 
peculiar tremor elicited by making tense the tumor between the fingers of 
one hand while it is gently percussed with the other. 
Sometimes the vesicles break into the pelvis of the kidney, and are expelled 
in such numbers as to obstruct the urethra and cause some embarrassment 
to the flow of urine. 
Treatment.-We are in possession of no medicines which possess any 
power to expel these parasites, and the only means which offers any hope 
of relief is the puncturing of the cyst with a trocar after the plan of 
Simon, or, when it has been once adherent to the abdominal walls, lay- 
ing the tumor open and treating it with iodine and other irritating liquids. 
Electro-puncture has also been advised. Certainly we are not at present 
in possession of a sufficient number of cases to justify any particular line of 
treatment. 
The strongylus gigas is derived from the dog, ox, horse, and some other 
animals, and resembles in appearance the ordinary earth-worm. Its habitat 
in the human kidney is the pelvis and calices of the organ. Of its mode 
of entrance nothing is known. The symptoms of its presence are those in- 
dicative of the presence of a foreign body, viz., frequent micturition, bloody 
urine, and lumbar pain. It is destructive to the structure of the kidney. 
The distoma hcematobium, first described by Bilharz, is a parasite most gen- 
erally encountered in hot climates. It is represented as being very common 
in Egypt, so much so that Griesinger is said to have discovered it 117 times 
in 363 bodies. The parasite is flattened anteriorly, round posteriorly, and 
has two suckers. Its ova, which are pointed at one extremity, are supplied 
with teeth. The embryos, though developed from the ova inside of the 
urinary organs, soon perish when exposed to the urine. Their presence can 
be detected only by the discharge of eggs in the urine. These parasites are 
instrumental in causing serious irritation and structural changes in the 
pelvis, the ureter, and the bladder, and are often the cause of renal dropsy. 710 
INJURIES AND DISEASES OF THE GENITO URINARY ORGANS. 
Renal Tuberculosis is ordinarily only a local manifestation of a general 
tuberculosis, though it may be a primary disease. The tubercles are deposited 
in both the medullary and the cortical portion of the kidney. In a majority of 
cases it is probably true that when the granulations are miliary the formation 
begins in the cortical portion of the kidney along the small arteries which lie 
between the pyramids of Ferrein, and also upon the surface of the gland. 
The connective and vascular tissues which occupy the intertubular spaces 
are found infiltrated with small round cells, which serve to compress or 
flatten the tubes. The epithelium of the latter becomes granular and fatty, 
adjoining granulations become confluent and caseous, and in time the entire 
secretory and receptive or pelvic portions of the organ are invaded and 
converted into a caseous and purulent mass. 
Nor is the deposit limited to the kidney. It sometimes invades the sub- 
mucous connective tissue of the ureter and bladder, and also involves the 
structure of the seminal vesicles and the prostate body. There is some slight 
discrepancy of opinion among pathologists on these neoplasms of the kidney. 
Some regard those masses of infiltration which possess a cheesy character as 
merely a retrograde metamorphosis of confluent groups of miliary tubercles, 
while others believe the cheesy nodules are often only a degeneration of 
the products of ordinary inflammation. Both conditions, I think, may exist 
at the same time, but the tubercular takes precedence, and becomes the ex- 
citing cause of the inflammatory. When the disease is part of a general 
tuberculosis, the patient does not survive long; but when its origin is pri- 
marily renal, it may have a chronic course. 
Symptoms.-The symptoms of renal tuberculosis resemble in so many re- 
spects those of pyelitis or of pyelonephritis as to render it difficult to estab- 
lish a distinction between the two affections. 
There is pain in the lumbar region, and later on in the disease a tumor can 
often be detected in the same region. The urine contains caseous pus and 
floating debris of disorganized connective tissue filled with small cells in an 
advanced granular and fatty state. Of course, from the presence of pus, it 
follows that the urine will be albuminous. There is a difference, however, 
between the albuminous urine met with in Bright's disease and that which 
is witnessed in renal tuberculosis. In the former the watei' is clear, and con- 
tains hyaline and other tube-casts, while in the latter the urine is opaque, 
cloudy, and rarely reveals under the microscope any tube-easts. 
The advanced stage of the disease is marked by rigors, emaciation, hectic 
fever, and exhausting sweats, the patient dying either from uraemic poisoning 
or from the exhaustion attending the progress of tubercular disease in other 
organs. 
Treatment.-The treatment is one simply of palliation,-of opposing the 
fatal progress of the disease by such agents as contribute to the nutrition of 
the patient. To this end, cod-liver oil, the preparations of malt, milk, and 
concentrated broths, will be useful; and as adjuvants, iron, quinine, and fresh 
air are important remedies. Severe nephralgia and lumbar pain will demand 
anodynes; and when the tumor appears externally, and collections of pus 
can be diagnosed by the grooved needle, aspiration of the contents of the 
swelling will afford temporary relief. 
Extirpation of the kidney, even if it could be shown that the disease was 
unilateral, would in an affection of this nature be entirely valueless. 
Renal Carcinoma appears rarely as a primary, generally as a secondary 
disease. When secondary in its origin, both kidneys are liable to be in- 
volved ; when primary, the right is most frequently affected. Ebstein, in a 
collection of 8300 cases of carcinoma, found only three cases of primary cancer 
of the kidney; and Steiner met with only four cases among 100,000 children 
in the Children's Hospital at Prague. When children are the subjects of the 
disease, it will probably appear at some period under the fifth or sixth year; 
among adults it usually appears after fifty. Renal cancer occurring in ad- RENAL CARCINOMA. 
711 
vanced life affects males far more frequently than females; but this rela- 
tion does not exist in children, as in 15 instances given by Ebstein 8 were 
boys and 7 were girls. It is in children that tumors of renal cancers attain 
their greatest bulk. 
Carcinoma of the kidney may appear as a medullary cancer or as a scir- 
rhus. The most common form is the hsematoid carcinoma. The colloid 
variety is more frequently encountered than the scirrhous. Renal epitheli- 
oma is rare. The disease often extends to the pelvis of the kidney and to the 
ureter, and is sometimes seen as a wide spread or diffuse deposit over the 
whole gland, finally obliterating all traces of renal structure; in other in- 
stances it appears in nodules disseminated through the organ, and these 
surmounted by irregular masses of the same character. The parenchyma 
between the cancerous nodules is frequently sound; often, contiguous to the 
deposits, it will be found to be congested and slightly infiltrated. In some 
places it is possible to find a mass or nodule of the disease isolated from the 
renal tissue by a well-defined capsule. In the haunatoid variety the most 
striking anatomical feature of the disease is the great dilatation of the capil- 
laries. When the infiltration is diffused throughout the kidney, the gland 
will in a great measure retain its form. 
Renal cancer begins in the epithelium of the uriniferous tubules. These 
tubes, when examined microscopically in the diseased district, will be seen 
to be filled with proliferating epithelial cells; nor is the intervening connective 
tissue passive. It becomes infiltrated and increased in amount. As in other 
glandular organs when attacked by cancer, so in renal carcinoma, cysts, hem- 
orrhagic infarctions, and unhealthy purulent collections are developed in the 
organ as the affection progresses. Renal cancer, unlike tubercular neoplasms, 
rarely ever attacks the ureter or the bladder. 
Kidneys attacked with cancel' exhibit a tendency to contract adhesions to 
surrounding parts, in consequence of the glandular irritation exciting inflam- 
mation in the capsule of the organ. Thus, they have been found adherent to 
the liver, to portions of the ileum, to the duodenum, to the colon, and to the 
walls of the abdomen. 
Secondary deposits follow cancer of the kidney, and these may be estab- 
lished by embolism of the renal vein, the walls of which are sometimes de- 
stroyed by the pressure of the surrounding deposit, and its cavity filled 
with the particles of the latter, which, being detached, are swept along the 
blood-stream of the lower cava to the heart, and thence to the lungs, where, 
being arrested in the pulmonary capillaries, they become foci of infection. 
Secondary deposits also form in the mesenteric and the retro-peritoneal 
glands. 
Causes.-The causes of renal cancer are obscure. So far as can be de- 
termined from the history of individuals, there are cases of the disease in 
which no hereditary influence can be discovered to explain its presence. 
Medical agents which exert an irritating effect on the kidneys have been 
regarded with suspicion in this connection. Traumatic violence has in sev- 
eral instances been followed by cancer of the kidney; and it is a singular 
fact that carcinoma of the testicle is not uncommonly succeeded by a like 
condition of the kidney. 
Symptoms.-The two most significant signs of renal cancer are the presence 
of a tumor and heematuria. The former generally appears in the loin, between 
the crest of the ilium and the last rib, and increases in a direction forward 
and upward. This enlargement is sometimes painful when pressed upon, at 
other times painless. Severe paroxysms of pain are often experienced, but 
they result from the pressure of the growth on contiguous nerves. The uni- 
formity of the presence of a tumor is quite striking: in 52 cases collected 
by Ebstein it was absent only three times. Hsematuria is occasionally noticed 
before any swelling in the flank. It may be quite slight, but in some instances 
it amounts to a copious hemorrhage, filling the pelvis of the kidney with 
clots, and even blocking up the ureter. Fibrinous coagula may also be passed 712 
INJURIES AND DISEASES OF THE GENITO-URINARY ORGANS. 
almost completely decolorized. The manner in which this occurs is not diffi- 
cult of explanation. The blood coagulates in the pelvis of the kidney or in 
the ureter, and the urine as it passes through washes out the blood-corpus- 
cles which have been entangled in the solidifying fibrin; finally the contrac- 
tion of the latter, with the presence of the water behind, expels the colorless 
clot. During the passage of these masses, the pain will often simulate that 
which accompanies renal colic. 
Nothing is to be learned from the urine. In quantity and reaction it does 
not necessarily differ from the normal secretion. It may, however, contain 
minute cancer masses, exhibiting the characteristic alveolar structure, which 
would be calculated to throw much light on the case, and hence the value, 
in obscure cases of kidney disease, of examining microscopically whatever 
detritus may appear in the urine. 
Jaundice has in a few instances been observed, when the disease was located 
in the right kidney, in consequence of pressure being exerted on the common 
bile-duct. When the cava and other abdominal vessels are compressed, or 
when a thrombosis extends from the emulgent veins into the inferior vena 
cava, there will occur ascites, enlargement of the superficial veins of the 
abdomen, and oedema of the lower extremities and the scrotum. It is only 
towards the termination of the disease, from infection and exhaustion, that 
febrile symptoms appear. 
Diagnosis.-There is confessedly much uncertainty in the diagnosis of 
renal cancer; indeed, there are no tumors within the abdomen which are 
so difficult of recognition as those of the kidney, let the disease be what it 
may. 
When the right kidney is implicated, it is liable to be confounded with 
disease of the liver. In drawing a distinction, the previous history becomes 
very important. Morbid growths of the liver begin above and descend. 
The reverse is true of those of renal origin. Besides, in tumors of the kidney, 
unless adhesions have taken place with the liver or the parietes of the abdo- 
men along the border of the ribs, the fingers of the surgeon, particularly in 
the recumbent position of the patient, may be insinuated between the margin 
of the thorax and the enlargement, when connected with the kidney, which 
is not possible in a hepatic growth. There will also be in affections of the 
former organ a line of resonance between the enlargement and the lower 
ribs, and not only so, but, as the colon lies in front of the kidneys, the tym- 
panitic sound of the distended intestine will be brought out by percussion 
over the tumor, if renal. 
When the tumor involves the left kidney, it is liable to be confounded with 
splenic enlargements. A very eminent surgeon of Philadelphia, distinguished 
as a diagnostician in abdominal tumors, recently died from what he very con- 
fidently believed to be cancer of the spleen, but which upon a post-mortem 
examination proved to be cancer of the kidney. And here the observations 
bearing on the differential signs of right renal cancer may be applied to the 
left. 
Ovarian tumors and ascites bear some resemblance to renal enlargements, 
but in the former the intestines and resonance are usually behind, not in front, 
as in the latter. Any uncertainty in the diagnosis may be dispelled by the em- 
ployment of the exploring needle or trocar. Enlargement of the mesenteric 
glands and renal cancer being both often met with in children, the differentia- 
tion of the two is not always an easy task. The fact, however, that in the 
former the growth is median, and will probably extend equally on both sides, 
while in the latter in most instances the tumor is unilateral, is not without 
special significance. In general, a growth which begins on one side of the 
body in children under five years of age or in persons over sixty, the surface 
of which is irregular, with lumbar dullness on percussion, and which grows 
rapidly, presenting unequal resistance at different parts of the surface, and 
accompanied with hsematuria, with loss of flesh, and with a cachectic appear- 
ance, may be declared to be a carcinoma of the kidney. NEPHROTOMY. 
713 
Prognosis.-Renal cancer is inevitably fatal. Age exerts considerable in- 
fluence over the period of its duration. In children a few months-eight or 
nine-suffice to bring about the fatal result, but in adults the disease may 
require one, two, or more years to destroy life. 
Treatment.-The treatment is palliative. Free bleeding must be con- 
trolled by haemostatics, as gallic acid, ergot, pernitrate of iron, acetate of lead, 
and turpentine. Pain must be moderated or removed by opiates, and the 
general condition improved by tonics, proper nourishment, and fresh air when 
the patient is not debarred by weakness from moving about. 
Nephrotomy. 
Nephrotomy is performed either through the lumbar region or through 
the anterior parietes of the abdomen. 
In lumbar nephrotomy the operation is performed by laying the patient 
on the breast, bent somewhat over a pillow rolled into a cylinder and placed 
under the abdomen, the body inclining a little towards the sound side. 
An incision commencing over the eleventh rib, a finger-breadth anterior 
to the edge of the erector spinae muscle, is carried perpendicularly downward 
to the crest of the ilium, dividing the skin and superficial cellulo-adipose 
tissue. The tendons of the internal oblique and transversalis muscles are 
next raised on a director and divided, exposing the quadratus lumborum, on 
which the kidney rests. The fibres of the muscles must be cut in the same 
general direction as that observed in the previous incisions, when the loose 
layer of connective and fatty tissue in which the kidney is imbedded will bo 
seen. This is to be broken through with the fingers until the organ is reached, 
which can then be enucleated and brought through the external wound. 
A strong ligature must now be made to encircle the vessels in mass or in 
two sections where they enter the hilus of the gland, when the latter can be 
severed from the included arteries, veins, and duct without difficulty. The 
wound is to be closed with interrupted sutures, a drainage-tube having been 
previously introduced to secure a free escape of any accumulation which may 
form in the lumbar region. 
Abdominal Nephrotomy.-When the kidney has been displaced from its 
normal position and approaches the anterior portion of the abdomen, its 
removal will be more easily accomplished by opening the parietes through 
the linea alba, as in the operation of ovariotomy. After the vessels of the 
organ have been exposed, the arteries and veins should be separated, and 
secured with strong carbolized silk ligatures in two places, the included ves- 
sels being divided between the threads so as to prevent blood from escaping 
into the abdomen. Both ends of the ligatures are to be cut off close to the 
knots, and after all bleeding, from whatever source, has been arrested by 
tying with catgut threads any small vessels which may have been wounded 
in exposing the diseased kidney, the walls of the abdomen are to be closed 
and supported by a bandage in the same manner as after the removal of 
ovarian cysts. In both abdominal and lumbar nephrotomy the operation 
should be conducted antiseptically. 
Nephrotomy has been performed for the relief of urinary fistula resulting 
from the division of the ureter in ovariotomy, for renal calculus, for gunshot 
wound, for pyelitis, for tumors, for cysts, and for floating kidney. 
The first operation of the kind was executed by Simon, of Heidelberg, in 
1869, on a female who had previously undergone ovariotomy, and who suf- 
fered from a urinary fistula in consequence of the ureter having been wounded 
at the time the cyst was extirpated. This patient recovered. 
The following table contains the chief cases of nephrotomy which have 
been recorded: 714 
INJURIES AND DISEASES OF THE GENITO-URINA RY ORGANS. 
Table of Cases of Nephrotomy. 
Operator. 
| Male. 
a 
u. 
Disease. 
Recovered 
Died. 
Source of Information. 
1. Simon. 
I 
46 
Urinary fistula fol- 
lowing ovariotomy 
from cut ureter 
1 
Deutsche Klinik, April 9, 
1870. Edinb. Med. Jour., 
May, 1870. Amer. Jour. 
Left kidney. 
Med. Sciences, 1873, p. 
279. 
2. Schetelig. 
Supposed ovarian cyst. 
! By abdominal sec- 
1 
Archiv fdr Gynakol., 1870. 
New Sydenham Society, 
1 tion. 
Biennial Retrospect, 
1869-70. Amer. Jour. 
Med. Sciences, 1873, p. 
278. 
3. Gilmore. 
1 
33 
Painful tumor, four 
1 
Amer. Jour, of Obstetrics, 
years' standing. 
Patient five months 
May, 1871. Amer. Jour. 
Med. Sciences, 1873, p. 
advanced in preg- 
279. 
4. Von Bruns. 
1 
nancy. 
Gunshot wound (con- 
1 
Centralblatt filr d. Med. 
vex portion of left 
Wissenschaften, No. 32, 
5. Meadows. 
1 
kidney removed). 
Cyst of the kidnev. 
i 1 
1871. Amer. Jour. Med. 
Sciences, 1872, p. 263. 
British Med. Journal, July 
Supposed ovarian 
8, and July 15, 1871. 
cyst. 
Amer. Jour. Med. Sci- 
6. Peters. 
1 
Calculous pyelitis. 
1 
ences, 1873, p. 277. 
New York Med. Jour., 
Right kidney. 
Nov. 1872. Amer. Jour. 
Med. Sciences, 1873, p. 
7. Durham. 
1 
43 
Supposed renal cal- 
culus. Kidney 
healthy. 
1 
277. 
British Med. Jour., May 
18, and May 25,1872. 
8. Peaslee. 
1 
Solid renal tumor. 
1 
Amer. Jour. Med. Sciences, 
Supposed to be ova- 
1873, p. 278. 
9. Simon. 
rian. 
1 
43 
Pyelitis. 
1 
Centralblatt filr d. Med. 
Wissenschaften, Mar. 28, 
1874. Amer. Jour. Med. | 
10. Brandt. 
1 
Wound. 
1 
Sciences, 1874, p. 266. 
Wiener Med. Wochen- 
schrift, Nov. 29 and Dec. 
6. Amer. Jour. Med. 
11. A. C. Campbell, 
Scotland. 
1 
Supposed ovarian cyst. 
Left kidney. 
1 
Sciences, 1874, p. 266. 
Edinburgh Med. Jour., 
June, 1874. Amer. Jour. 
Med. Sciences, 1875, p. 
12. Marvard. 
282. 
1 
Wound in kidney. 
1 
Canadian Journal Med. i 
Science, March, 1876. ! 
Amer. Jour. Med. Sci- 
13. Not given. 
1 
Cyst of kidney mis- 
taken for cystic kid- 
1 
ences, 1876, p. 586. 
Gaz. Med, No. 6, 1876. 
N'-w York Med. Jour., 
ney. Left kidney. 
1875. Amer. Jour. Sled. 
14. Langenbeck. 
1 
32 
Cyst of left kidney. 
1 
Sciences 1876, p. 281. 
Berliner Klinische Woch- ! 
Operation antisep- 
enschrift, No. 24, 1877. 
tic. 
Amer. Jour. Med. Sci- 
15. Kocher. 
Sarcoma. 
1 
ences, 1877, p. 579. 
Deutsche Zeitschrift filr 
Chirurgie, Band ix., 1 
Heft 3 und 4. Amer. 
Jour. Med. Sciences, 1878, 
16. Jessop. . 
Encephaloid. Left ■ 
Result 
unknown. 
p. 557. 
Lancet, January 17, 1877. 
kidney. 
Amer. Jour. Med. Sci- 
17. Smyth. 
1 
35 
Floating (right) kid- | 
ney sound. 
1 
i 
ences, 1877. p. 580. 
New Orleans Med. Society 
Jour., Aug. 1879. Amer. 
Jour. Med. Sciences, 1879, j 
18. Not given. 
11 
49 
Renal cyst mistaken 
1 
p. 575. 
La France Medicale, No. 1 
for ovarian cyst. 
99, p. 783. Hospital Gaz., i 
March 15, 1879. Amer. 
Jour. Med. Sciences, 
19. Stoddard. 
1 
58 
Encephaloid disease of 
kidney mistaken for ' 
1 
1879, p. 263. 
Med. and Surg. Reporter, 
1861, vol. ii.p. 126. Amer. 
cystic disease. 
Jour. Med.Sciences,1874, 
20. Reported by 
Zweifel. 
1 
Uretero - uterine fis- j 
tula, left side. 
1 
p. 268. 
Archiv filr Gynakologie, 
Band xv. 
21. Reported by Mar- 
tin. 
1 
1 
Langenbeck's Archiv, 1879, 
Band xxiii., 3. NEPHROTOMY. 
715 
Table of Cases of Nephrotomy.-Continued. 
Operator. 
<D 
* 
'2 
8 
£ 
bJO 
◄ 
Disease. 
Recovered 
Died. 
Source of Information. 
22. Thornton. 
23. Zerny. 
1 
50 
Cystic disease, 
kidney. 
Kenai tumor. 
Left 
Aorta 
1 
1 
British Med. Jour., Jan. 
31,1880, pp. 171-173. 
24. Zerny. 
25. Andrew, J. 1 
Callender, G. W. j 
1 
52 
44 
ligated. 
Pyonephrosis. 
1 
1 
St. Barth. Hosp. Reports, 
1873, vol. ix. pp. 213-220. 
26. Annandale. 
42 
1 
Edin. Med. Journal, July 
1869. 
27. Dawson. 1 
Bartholow.) 
50 
1 
The Clinic, 1872, pp. 205- 
208. 
28. Moxon. 1 
Bryant. J 
29. Williams, M. H. 
32 
1 
1 
Lancet, 1870, vol. vii. p. 292. 
New York Med. Record, 
1876, vol. xi. pp. 475-477. 
14 
14 
Of the 29 removals of the kidney tabulated above, 14 recovered, 14 died, 
and in 1 the result was not ascertained, though the patient was doing well 
one week after the operation. This is certainly an encouraging result to be 
obtained from so grave an operation. 
So far as could be ascertained, 16 of the patients were females and 7 males. 
The frequency with which the left kidney was the subject of disease is quite 
striking. The particular organ was mentioned in 10 of the cases, 8 being in 
the left and 2 in the right kidney. In 5 of the nephrotomies the disease had 
been mistaken for ovarian cysts. 
Under what circumstances nephrotomy is to be practiced is the question 
which concerns the surgeon. Unquestionably the diagnosis of many renal 
diseases is exceedingly obscure, and it may be said that only when there 
exists a certainty that one organ alone is the subject of disease, and that of 
a non-malignant nature, and which must necessarily, if not removed, event- 
uate in the death of the patient, should the extirpation of the kidney be con- 
templated. This rule will exclude all cases of renal cancer, and will include 
those of large or impassable renal calculi, of cystic disease, of pyonephrosis, 
and of persistent hydronephrosis, conditioned in all cases on the severity 
and threatening nature of the constitutional symptoms. To the above may 
be added a certain small number of floating kidneys, in which, from repeated 
strangulation, or from extreme nervous distress, due to the mobility of the 
organ, nephrotomy might with propriety be resorted to. CHAPTER XXI. 
SURGICAL DISEASES OF WOMEN. 
The diseases peculiar to women and usually requiring surgical treatment 
-and it is only these which I propose to consider-will be described in the 
following order: 
1. Surgical Diseases of the External Genitalia and Perineum. 
2. Surgical Diseases of the Vagina. 
3. Surgical Diseases of the Uterus. 
4. Surgical Diseases of the Ovaries. 
5. Surgical Diseases of the Urethra. 
Surgical Diseases of the External Genitalia. 
Adhesion of the Labia.-It is not uncommon to find the opposing surfaces 
of the labia majora in infants adherent. The condition, though generally 
congenital, is sometimes an acquired one, and is the result of carelessness 
on the part of nurses, who fail to maintain the proper cleanliness of the 
parts, in consequence of which the surfaces become abraded and finally ad- 
here to each other. Generally the union is quite soft. The malformation is 
usually detected and treated early. Should it be overlooked until girlhood, 
the bond of connection becomes converted into mature connective tissue, and 
requires more decided measures for its division than in infancy. 
Treatment.-The operation of separating the adherent labia is an exceed- 
ingly simple one, requiring only that the child be placed on its back on the 
nurse's knees, the limbs being at the same time bent forward on the body, 
while the surgeon introduces a probe or a director at the upper angle of the 
united labia, and, pushing it between the latter, carries it downward through 
the line of adhesion, which readily gives way before the pressure of the in- 
strument. To prevent re-adhesion, a piece of soft lint or old linen moistened 
with sweet oil or oxide of zinc ointment must be interposed between the 
margins of the separated labia, and renewed until the abraded surfaces have 
cicatrized. Often all that is necessary to effect the separation is merely to 
pull the labia asunder with the fingers. When this malformation has been 
overlooked, and the infant allowed to grow into girlhood without surgical 
interference, the union becomes strong and membranous, and will require to 
be divided with the bistoury on a grooved director. 
Wounds of the Labia are produced by falls astride of a pointed body, by 
the breaking of a chamber urinal while urinating in the sitting posture, and 
sometimes by the horn of a vicious animal. These wounds bleed quite freely, 
in consequence of the vascularity of the parts, and when sufficiently deep to 
implicate the plexus of veins which surround the vestibule (pars intermedia') 
the hemorrhage may be sufficient to cause death. Sir James Simpson has 
furnished a number of instances of fatal pudendal hemorrhage from violence 
done to the labium. 
Punctured wounds are frequently followed by considerable diffuse subcu- 
taneous infiltration of blood into the loose connective tissue of the labia. 
Treatment.-The treatment consists in securing any vessels which may 
continue to bleed, and uniting the sides of the wound by interrupted sutures, 
using for the purpose (because of the elasticity of the tissues) fine silk car- SURGICAL DISEASES OF THE EXTERNAL GENITALIA. 
717 
bolized thread, and for the subsequent dressing carbolized oil or laudanum 
and water. 
Should the hemorrhage prove obstinate and general, coming from numer- 
ous points, pressure must be made by inserting a compress a short distance 
into the vagina, placing another on the inside of the labium, and securing 
the two in place by a T bandage. 
Contusions of the Labia may be followed by an abundant eechymosis or 
extravasation of blood, forming a considerable swelling. The purple or dark 
discoloration and the history of an antecedent injury are sufficiently con- 
clusive as to the nature of the swelling. 
Treatment.-Lotions of lead-water or of dilute alcohol answer a good pur- 
pose as discutients. In time even very large accumulations of blood will 
be absorbed. As in the scalp, so in the labia, the blood in these swellings 
remains fluid, or, if coagulated, is in very soft, semi-liquid clots. 
Pudendal Hsematocele, or Thrombus, is a swelling consisting of blood, sit- 
uated in the subcutaneous connective tissue of one of the labia, and when 
of an aggravated degree will extend even into the cellular tissue around the 
vagina. Pudendal hsematocele is not peculiar to the parturient female, but 
is occasionally witnessed in the non-pregnant. The causes which give rise 
to these hemorrhages are predisposing and exciting. 
Whatever interferes with the free return of the blood from the pudendal 
plexus of veins will, by causing the distention of their walls, predispose these 
vessels to rupture. Among these causes may be named pelvic or abdominal 
tumors, and pregnancy. In this condition, the violent muscular efforts ex- 
cited in labor, or a slight blow on, or wound of, the labium, will determine the 
hemorrhage. 
The circumstances under which the accident occurs are sufficiently diag- 
nostic of the affection, which has neither the inflammatory history of an 
abscess, nor the change of location by pressure or position noticed in pudendal 
hernia. 
Treatment.-If the swelling is not large, its removal may be safely left 
to natural processes, lending some assistance by the use of evaporating lotions 
of lead-water and laudanum, together writh gentle pressure by means of a 
compress and T bandage. 
When, on the other hand, the tumor continues to increase in size, or the 
presence of blood provokes inflammation and abscess, it should be laid open 
freely, the clots turned out with the finger, the cavity washed out with car- 
bolated water or a solution of permanganate of potash, and the parts sup- 
ported by a compress and bandage. In the event of the bleeding continuing, 
the vagina will require to be packed, and the labium compressed, as in cases 
of obstinate bleeding after wounds. 
Abscess of the Labium is by no means uncommon. It occurs both in the 
married and in the unmarried female, and may follow the violence of sexual 
intercourse, or may originate in a folliculitis. The disease is recognized by 
the heat, pain, swelling, and undue redness of the parts. 
Treatment.-The suppuration is to be favored by the application of warm 
flaxseed-meal poultices, and the abscess laid open when the fluctuation be- 
comes distinct. 
(Edema of the Vulva arises chiefly from two causes, the one non-inflamma- 
tory, and the other inflammatory. Mechanical pressure alone may produce 
it, as may be witnessed during the latter months of pregnancy, when the 
uterus encroaches on the venous trunks of the body, or when a large ovarian 
cyst or uterine fibroid offers a similar impediment to the venous current. 
Contusions and phlegmonous erysipelas are inflammatory causes of the 
same condition. The swelling is sometimes very great. 718 
Treatment.-When oedema arises from pressure within the abdomen, its 
cure can be effected only by the removal of the cause. After parturition the 
swelling disappears: indeed, the tumefaction is often less in the last months 
of gestation than at an earlier period, as the ascent of the uterus relieves the 
pelvic veins from pressure. Even when the oedema is due to abdominal or 
pelvic tumors, it may be relieved spontaneously by the morbid growth 
changing its position. Should the swelling become very large, threatening 
disorganization, two or three punctures will remove the extreme distention 
by draining away the serum. When the oedema is the result of phlegmonous 
erysipelas, and the infiltration endangers the vitality of the labium, a free 
incision becomes necessary. 
SURGICAL DISEASES OF WOMEN. 
Gangrene of the Vulva is preceded by a tumefied purple appearance of the 
labia, attended by symptoms of grave constitutional disturbance. One or 
more vesicles of a gray color make their appearance in the vulva. These 
soon become filled with bloody serum, and are surrounded by a zone of in- 
durated tissue; the vesicles run rapidly into ulceration, and finally mortifica- 
tion, which, unless promptly arrested, ends in the death of the patient. 
The disease is dependent on a vitiated and depraved state of the blood, 
and is prone to attack women of dissolute lives, or pale, puerperal, aneemic 
females. Children are not exempt from the disease, and when it occurs in 
this class of patients it is a sequel to certain exanthemata, as scarlet fever 
or measles, and diphtheria. The disease has in some instances assumed the 
form of an epidemic. 
Treatment.-As in hospital ulceration or gangrene, so in gangrenous vul- 
vitis, an apartment well ventilated and the strictest attention to cleanliness 
are of the first importance in treatment. The local extension of the de- 
structive process must be promptly arrested by a potent caustic, such as 
bromine or the acid nitrate of mercury. The severity of these applications 
requires the employment of an anaesthetic. After the caustic has been 
thoroughly applied, the parts must be covered with warm flaxseed-meal 
poultices, any loose or detached portions of the sloughs should be removed, 
and the remaining part well disinfected by washes of permanganate of potash. 
The general strength is to be sustained by the very best nourishment which 
the patient can take, aided by stimulants and tonics, quinine, and tincture 
of iron. 
Inflammation of the Vulvo-Vaginal Glands.-These conglomerate glands, 
which lie between two layers of the ischio-pubic fascia, having each a duct 
about half an inch in length, opening on each side of the entrance of the 
vagina, become the seat of inflammation, characterized by heat, redness, 
itching, and tenderness of the vulva. The inflamed gland forms a circum- 
scribed mass, which may be felt by introducing a finger into the vagina and 
pressing outward towards the ramus of the ischium. 
The disease, unless early recognized and promptly treated by the local 
abstraction of blood, a purge, and lotions of warm lead-water and laudanum, 
is liable to terminate in suppuration, or in the formation of a cyst by the 
occlusion of the duct. 
Abscess.-When suppuration follows, it may be recognized by the ordinary 
signs of precedent inflammation and by fluctuation. The pus is sometimes 
discharged through the excretory duct of the gland, or it may be conducted 
forward between the layers of the ischio-pubic fascia, and escape on the sur- 
face, at a point between the lesser and greater labia. 
Treatment.-When antiphlogistic measures fail to secure the resolution 
of the inflammation, the suppuration should be hastened by warm fomenta- 
tions or poultices, and the surgeon must make an opening into the collection 
at any place where it exhibits a disposition to point. 
Cysts.-When cystic degeneration of the glands of Bartholini or of their 
excretory ducts occurs, the only plan of effecting a permanent cure is either FOLLICULAR DISEASE OF THE VULVA. 
719 
to excise the body in its entirety, or to destroy it through suppuration and 
granulation. 
Excision requires that a vertical incision be made between the junction of 
the two labia of the affected side. A little dissection, with one finger in the 
vagina to press the gland towards the surface, will render its removal quite 
easy. Rarely will more than a single vessel (the transverse perineal artery) 
require the ligature. 
Incision consists in laying the sac open by a cut similar to that made for 
the excision of the gland, turning out the clear, syrup-like contents, and 
packing the,cavity with a little carbolized lint, until it becomes closed by 
granulation. Either plan will prove effectual. Cauterization of the sac, 
after its cavity has been exposed, has also been recommended; but it will 
be more likely to fail than when the stuffing method is adopted. 
Follicular Disease of the Vulva is an inflammation of the solitary glands 
which are scattered over the vulva. There are two varieties of glandular 
bodies occupying the labia and other 
parts of the vulva,-the sebaceous and 
the muciparous glands. The disease 
may involve one or both of these. The 
symptoms of this folliculitis are heat, 
redness, burning, and itching, with in- 
filtration of the connective tissue of the 
follicle (Fig. 1426), and the formation of 
vesicles containing a thick, ropy fluid 
when the muciparous glands are in- 
volved, or a little cheesy or purulent 
matter when the disease is in the seba- 
ceous glands. 
Follicular vulvitis sometimes appears 
during gestation, and may also arise 
from indifference to cleanliness, also 
from the irritation of the mucous sur- 
face of the vulva by leucorrhoeal dis- 
charges, or by those coming from car- 
cinoma of the uterus. The disease 
assumes occasionally a chronic form, 
and extends into the urethra. 
Treatment.-The remedies best 
adapted to a case of folliculai' vulvitis 
are washes of carbolated water, lauda- 
num and water, tar-waters, or warm 
chamomile tea, followed by light flax- 
seed-meal or slippery-elm poultices. Penciling the parts with a weak 
solution of nitrate of silver (three or four grains to the ounce of distilled 
water) also exerts a salutary influence over the disease; and the same 
is true of dilute hydrocyanic acid and lime-water (equal parts), which can 
be applied by moistening strips of old linen with the liquid and placing 
them over the parts. The disease when developed during pregnancy will 
sometimes resist all remedial applications, and subside spontaneously after 
parturition. 
Fig. 1426. 
Follicular disease of the vulva. 
Hypertrophy of the Labia.-The labia majora are most frequently the seat 
of hypertrophy. The enlargement is sometimes unilateral, at other times 
bilateral. The growth in simple hypertrophy rarely exceeds in size that 
of an orange. It is oblong in figure, the surface being either ridged or 
wartlike (Fig. 1427), and, histologically, consists of an increase in the normal 
constituents of the part. 
The causes which are chiefly instrumental in determining hypertrophy  SURGICAL DISEASES OF WOMEN. 
of the labia are venereal. As the labia increase in size the mucous surfaces 
often become ulcerated from attrition, 
and are covered by exceedingly offen- 
sive discharges. 
The remedy is excision: this should 
be executed by reflecting a flap of 
skin, and also one of mucous mem- 
brane, after which the intermediate 
dense mass of fibrous tissue consti- 
tuting chiefly the hypertrophy should 
be removed, and the flaps stitched 
together by a few interrupted sutures, 
the wound being dressed afterwards 
with a water or carbolated oil dress- 
ing. 
When the skin has undergone 
much structural alteration, being 
rugose or warty, it should be sac- 
rificed in common with the other 
portions of the labium; and as the 
latter, when thus altered, contains 
a large number of small vessels, from 
which much blood may be lost, it is 
best to precede the removal of the 
pendulus by transfixing its base with a sufficient number of pins, around 
which ligatures can be tied to command the bleeding; or the hemorrhage 
may be arrested by the use of the thermo-cautery. 
720 
Fig. 1427. 
Hypertrophied labia. 
Elephantiasis is rarely seen in this country. It is not limited to the labia 
majora, but includes the lesser labia and the clitoris, and does not differ in 
structure or in treatment from the same disease elsewhere. 
Varicose Veins.-The venous plexus which lies beneath the labia (pars in- 
termedia} is occasionally the seat of a varicose enlargement, forming a con- 
siderable mass of dilated and tortuous trunks, the walls of which are some- 
times quite thin, giving to 
the swelling a blue color; 
or they may be slightly 
altered in their structure. 
During gestation these var- 
icose veins are much in- 
creased in size from the me- 
chanical obstruction to the 
intra-pelvic venous circula- 
tion, and become the source 
of uneasiness to the pa- 
tient, who is led to antici- 
pate rupture and hemor- 
rhage. (Fig. 1428.) The 
disease occurs both in the 
young and in the middle- 
aged female, but rarely under 
any other condition than 
that associated with preg- 
nancy, though occasionally 
cases have been witnessed 
in which the varicosity of the plexus was quite independent of the gravid 
uterus, but connected with a like state of the veins of the lower extremities. 
Treatment.-Operative measures are never demanded unless in the event 
Fig. 1428. 
Varicose veins of the labium. EPITHELIOMA OF THE LABIUM. 
721 
of rupture, which might follow the pressure of the foetal head as it emerges 
from the pelvis, when the ligature would be required. After parturition, the 
cause of the distention being in a great measure removed, the vessels resume 
their normal size, and cause no further inconvenience. In one case of a 
young primipara who consulted me on account of a large spongy bunch of 
varicose veins of the right labium, the disease did not recur in the gestations 
which followed the birth of the first child. Some palliation may be obtained, 
when the enlargement becomes troublesome, by enforcing rest in the recum- 
bent position and preventing fecal accumulation in the lower bowel. 
Warts are quite common on the vulva. They appear frequently in great 
numbers, have a pale red color, 
and are sometimes so closely 
grouped together as to form 
cauliflower-looking excres- 
cences. These papillomatous 
growths often extend up into 
the vagina, and have almost 
invariably a gonorrhoeal or 
syphilitic origin. A form of 
papilloma has been described 
by Emmett under the name of 
oozing tumor of the labium. 
(Fig. 1429.) 
Treatment.-This consists 
in touching the excrescences 
from time to time with the acid 
nitrate of mercury or chromic 
acid, and packing the vulva 
with lint, frequently renewed, 
so as to absorb all moisture, the 
presence of which favors the 
growth of these bodies. In ob- 
stinate cases in which caustics 
do not answer the purpose, 
these wmrts can be clipped off, 
and the surface touched with a 
crayon of nitrate of silver or 
nitric acid. When the bleed- 
ing continues for any time, the 
raw surface should be covered 
with the persulphate of iron, and a compress bound upon the vulva for eight 
or ten hours. 
Fig. 1429. 
Papilloma of the labium. 
Epithelioma of the Labium is quite a common affection, and oftener seen in. 
females after fifty years of age than at any other period of life. It begins much 
in the same manner.as does the same disease when seated in the lower lip, 
either as a fissure or crack, or as a wart-like excrescence, situated at the junc- 
tion of the skin and mucous membrane of the labium, either on the side of 
these cutaneo-mucous folds or at their superior commissure. (Fig. 1430.) The 
ulceration is irregular, with undermined borders, and with more or less sur- 
rounding infiltration or induration; the pain is sharp and lancinating, and 
the discharges are unhealthy, mixed with blood, and possessed of an offensive 
odor, with a disposition, as the destructive process advances, to implicate the 
lymphatic glands in nearest relation to the disease (as the inguinal), and also, 
with a tendency to profuse bleedings. Epithelioma may be confounded with 
a syphilitic sore. A careful inquiry into the history of the case will prevent 
an error of this kind. It may also be observed that the venereal ulcer never 
gives rise to the severe pain of cancer, and yields readily to internal treatment. 
vol. ii.-46 722 
SURGICAL DISEASES OF WOMEN. 
Treatment.-The only hope of removing the disease is in an early excision, 
before the affection has extended too much to allow the knife to include in 
Fig. 1430. 
Epithelioma of the labium. 
the operation healthy tissue. When the glands have become contaminated, 
operative measures will prove valueless, except in the way of palliation. 
Tumors of the Vulva. 
The morbid growths which are commonly encountered in this region are 
fibro-myomatous, adipose, sebaceous, cystic, myxomatous, carcinomatous, 
and, in rare instances, neuromatous. 
Fibrous Tumors of the Vulva are deeply imbedded in the substance of the 
labium when primarily originating in the latter: they are movable, somewhat 
pyriform in shape, and encapsulated,-peculiarities which will prevent their 
being confounded with simple hypertrophy of the labium. It is, however, 
in hot climates that these growths are seen most frequently and oftenest 
attain considerable magnitude. Though the preponderating element of these 
neoplasms is connective tissue in different stages of development, they fre- 
quently-particularly when of long duration-contain cavities which are 
filled with different kinds of fluids. 
Treatment.-Excision alone will remove the disease. In performing this 
operation, the surgeon must remember that the growth may send a pro- 
longation upward between the vagina and the ramus of the ischium into 
the pelvis; or it may have originated within the latter, and have involved 
the labium secondarily. In either event, the portion extending within the 
pelvis, when it cannot safely be exposed to the full extent, should be ligated 
and cut off below. 
Adipose Growths I have never seen in the structure of the labium, though 
they have been observed by others. They can be easily recognized by their 
soft, doughy, inelastic feel, and by the fissures or dimples which appear on 
compression, marking the dip of the interlobular connective tissue. 
Excision is the remedy. 
Sebaceous Tumors are almost as rare as the adipose. I can recall but a 
single case of the kind. It was about the size and the shape of a marble, 
and moved freely under the finger. The treatment is excision. TUMORS OF THE VULVA. 
723 
Cystic Growths may develop in the labium and grow to a large size. They 
have sometimes a traumatic origin, their beginning being around a little clot 
of extravasated blood, or they may arise from one of the mucous glands. 
(Fig. 1431.) The wall of the cyst is formed out of the condensed cellular 
Fig. 1431. 
Cyst of the labium. 
tissue of the labium, and contains a clear serum, or, when formed from a 
mucous gland, a ropy, straw-colored fluid. These tumors are either spherical 
or oblong in shape, and possess considerable elasticity. The grooved needle 
can be resorted to when any doubt exists as to the nature of the enlargement. 
They are most satisfactorily treated by excision, which, to be effectual, must 
include the cyst-wall. 
Myxomatous Tumors are very rare in the labium, and require excision 
for their cure. Encephaloid, scirrhous, and sarcomatous tumors of the labia 
are of rare occurrence. The first two are generally extensions of the dis- 
ease from other portions of the genital tract, as the vagina, the uterus, or 
the clitoris. 
Clitoris.-Wounds of the clitoris are exceedingly rare. When an acci- 
dent of this nature takes place, the 
hemorrhage is profuse, and has been 
known to terminate fatally. The 
bleeding can be most satisfactorily 
controlled by a pin and twisted liga- 
ture. 
Hypertrophy of the Clitoris is 
quite common in Eastern countries, 
where, indeed, in consequence of the 
early development of the sexual 
apparatus, the normal size of the 
organ is greater than in more tem- 
perate latitudes. 
It is thought by some that the 
growth of the clitoris is often pro- 
voked by systematic excitation of 
the parts from handling or from 
venereal excess; but there is no evi- 
dence that such is the case. (Fig. 
1432.) Women of the town and 
masturbators do not differ mate- 
rially in this respect from those whose lives are pure. In cases of hyper- 
Fig. 1432. 
Hypertrophy of the clitoris. 724 
SURGICAL DISEASES OF WOMEN. 
trophy of the clitoris the nympbse often partake of the enlargement, the 
tumor then having a pedunculated form. 
Treatment.-When the hypertrophy has attained a large size it will 
require to be removed, an operation which is most safely accomplished by 
pushing a pin through the pedicle of the mass and surrounding it with a 
thread before cutting away the growth. In this way bleeding can be pre- 
vented. 
Clitoridectomy has been performed for the cure of epilepsy. The number 
of successful cases which have been recorded from time to time amply jus- 
tify this procedure, unless, as has been proposed by White, of Buffalo, the 
division of the pubic nerves which supply the organ should be found to 
answer the same purpose as amputation, in which event neurotomy ought 
to be substituted. 
Pruritus of the Vulva, though sometimes a true neurosis, is in a large 
proportion of instances secondary to morbid conditions located elsewhere, 
causing an excessive irritability of the nerves distributed to the vulva. 
Symptoms.-The earliest intimations of the disease consist in a feeling of 
irritation in the parts, with some beat and a desire to scratch. These symp- 
toms may appear only when the patient has been somewhat overheated, or 
they may arise at certain times in the day, or on retiring to bed at night. 
In aggravated cases of pruritus the burning and itching become so intol- 
erable, and the impulse to scratch so irresistible, that the mucous surface of 
the vulva becomes inflamed and abraded. When the paroxysms are noc- 
turnal, the patient is entirely deprived of sleep and rendered miserable 
through the day. The disease is not always confined to the external geni- 
talia, sometimes extending into the vagina and to the inside of the thighs 
and over the abdomen, frequently accompanied with an eczematous eruption. 
So distressing does this affection sometimes become that I have seen women, 
in a frenzy of suffering, lose all sense of modesty, and, while detailing their 
symptoms, commence vigorously to scratch. Some, in despair, become melan- 
choly, and even exhibit suicidal tendencies. 
Causes.-The causes of pruritus are numerous. Among them may be 
mentioned discharges from the uterus, from the vagina, or from the urethra, 
indifference to personal cleanliness, pregnancy, urinary incontinence, inflam- 
mation of the vulva or of the vagina, diabetes, sexual excess, onanism, para- 
sites, and a depressed state of the system at large. Among those named, 
leucorrhoea is by far the most common. 
Treatment.-The first object of the practitioner should be to discover the 
cause on which the puritus depends, and as far as possible effect its removal. 
Unless this is done, no treatment can be followed by permanent benefit. 
In the mean while, remedies calculated to alleviate the pruritus should be 
used. That these may exert their proper influence, the utmost attention 
to cleanliness must be observed, for which purpose douches and ablutions 
with warm water two or three times a day are required ; after which various 
medicated substances can be used to allay the irritation and hypersesthesia, 
as solutions of borax, of acetate of lead or acetate of zinc, decoctions of 
chamomile flowers, infusion of tobacco, tar-water, and water impregnated 
with carbolic acid. Of these there are three which prove most efficacious 
in subduing the severe itching, ranking in point of value much in the order 
in which they are named,-carbolic acid and water (one drachm of the acid 
to one pint of water), infusion of tobacco, and tar-water. The bichloride 
of mercury also enjoys a deserved popularity as a wash. Fifteen or twenty 
grains of the salt dissolved in four ounces of water, either with or without 
the addition of a little laudanum, may be applied directly to the parts. 
When the disease has been induced by parasitic irritation, for example, 
that incident to the presence of the pediculus pubis or the acarus scabiei, 
mercurial ointment for the first and sulphur ointment for the second will 
answer the best purpose. TUMORS OF THE VULVA. 
725 
The late Professor Charles D. Meigs discovered short, stiff hairs growing 
from the mucous surfaces of the labia, which from their misplaced position 
caused considerable local irritation. When seeking for the causes of pruritus, 
the possibility of the presence of these hairs should not be overlooked, and 
if they are found they should be destroyed by depilatory agents. 
Hymen.-The hymen is liable to be involved in inflammatory affections 
of the vulva, and may become the seat of syphilitic ulceration. Though 
generally a delicate structure and easily lacerable, it sometimes possesses 
sufficient strength to offer an insuperable obstacle to successful intercourse. 
A case of this character came under my observation in which the membrane 
had resisted for several months every advance of the lady's husband, and 
required to be divided with the bistoury. 
Vaginismus, though recognized by Dupuytren, Michon, Burns, Simpson, 
and Scanzoni, has been more particularly described by Sims. 
This neurosis consists in a supersensitive state of the nerves at the orifice 
of the vagina, producing a rigid contraction of the sphincter vagina) muscle, 
and rendering the parts so extremely sensitive and painful to the slightest 
touch as to make all attempts at intercourse impracticable. 
This affection may be idiopathic or symptomatic. When of the former 
nature, it will be found in females of a highly nervous, sometimes hysterical 
organization. When vaginismus is secondary to local irritation elsewhere, 
the cause may be traced to an irritable carbuncle, or to an ulcer on the pos- 
terior fourchette, as was the case in one of my own patients. Scanzoni 
discovered that in 25 cases the cause could be traced to uterine disease, as 
dysmenorrhoea, amenorrhoea, metritis, etc. Dr. Neftel, of New York, traced 
the disease in four cases of vaginismus to lead-poisoning. Females who labor 
under this affection suffer exceedingly in all attempts at coition, are thrown 
sometimes into violent nervous paroxysms of trembling, and are usually 
sterile. 
There can be no difficulty in recognizing this condition. The slightest 
touch of the orifice of the vagina with the finger, or even with a feather, 
will cause the patient to start and to cry out with pain. 
Treatment.-A careful examination should be made in every case of vagi- 
nismus before adopting any treatment, to see if a sufficient local cause exists 
in the condition of the uterus, vagina, or rectum, and, if any such is dis- 
covered, measures must be instituted for its removal. When none can be 
detected, there are two courses open to the surgeon,-the one by anaesthesia 
with dilatation, and the other by i'ncmon. I was at one time favorable to 
the use of the knife, but after a larger experience in the management of this 
affection I believe the cases which require incision are very few indeed. 
Professor Penrose, who has treated many cases of this affection, informs 
me that he never resorts to the knife; and the testimony of Dr. Wilson, of 
this city, is to the same effect. 
Anaesthesia and dilatation.-The patient being etherized, placed on her back, 
and brought with the hips to the edge of the bed and the limbs supported, 
the surgeon introduces the index fingers back to back, well oiled, into the 
vagina, and then forcibly stretches its orifice to the fullest extent, maintain- 
ing the dilatation for three or four minutes, thus paralyzing the sphincter of 
the ostium. A moderate-sized rubber speculum, three inches in length, and 
covered by a shield of old linen or lint well smeared ovei' with an ointment 
of belladonna, is now introduced into the vagina, and retained in place for 
twenty-four hours with a T bandage; after which it can be removed, and 
a one-grain vaginal suppository of extract of belladonna introduced. For 
eight or ten consecutive days it will be necessary to insert this speculum and 
allow it to remain for five or six hours, in order to maintain the advantage 
gained and to obtund still furthei' the sensibility of the parts. During this 
treatment the patient should remain quiet in bed, use once a day vaginal 726 
SURGICAL DISEASES OF WOMEN. 
douches of warm chamomile tea, or of plain warm water with a little laudanum 
added, and live separate from her husband. 
Incision.-The operation practiced by Dr. Sims, and which would be proper 
in a case where dilatation had failed to afford relief, is performed in the fol- 
lowing manner. The patient, being etherized, is placed in the lithotomy posi- 
tion, and the remains of the hymen are clipped away by the curved scissors. 
The fourchette is now placed on the stretch by the middle and index fin- 
gers of one hand being introduced into the vagina and separated, when 
with the other hand the operator by means of a bistoury makes a deep in- 
cision, commencing a little on the right of the median line, and terminating 
at the perineal raphe. A similar cut is made on the opposite side, the two 
uniting at the raphe. A conical glass tube or dilator, closed at one extrem- 
ity, and measuring in diameter one inch to one inch and a half, is inserted 
into the vagina, where it is retained by a T bandage for two or three hours, 
morning and evening, according as it may be borne by the patient. This is 
to be kept up for three or four weeks, or until all inordinate sensibility dis- 
appears. 
In reference to incision, I may say that two cuts three-eighths to half an 
inch in extent, and carried obliquely outward on either side from the median 
line, or even a single cut the same length in the line of the perineal raphe, if 
followed by forcible stretching, will answer quite as well as the incisions 
described above. 
There are cases of vaginismus in which the supersensitive and rigidly con- 
tracted condition of the ostium vaginae is symptomatic of an irritable state 
of the general nervous system, and which require, in order to render local 
treatment successful, the use of constitutional remedies, as iron, quinine, 
strychnia, arsenic, valerian, sea-bathing, and a life much in the open air. 
Lacerations of the Perineum. 
Rupture of the perineum is not an uncommon accident. It generally 
occurs during first labors. In ninety per cent, of the cases which have come 
under my own observation it occurred in primiparae. When we take into 
account the enormous distention to which the foetal head subjects the 
normal perineum, not exceeding one inch and a half in length, and the con- 
sequent thinning of the tissues which compose it during the final stage of 
labor, it is no matter of surprise that these cases of laceration are so often 
witnessed. 
Causes.-The causes of ruptured perineum may be considered under three 
heads: first, those connected with the mother; second, those belonging to 
the child; and, third, those referable to the use of instruments. Under the 
first may be mentioned powerful uterine contractions, suddenly extruding 
the foetus before the resistance of the parts has been sufficiently overcome; 
deficiency in the tone of the muscular components of the perineum, rendering 
it incapable of reacting against the pressure of the head or other presenting 
part of the child; and sudden recurrence of suspended uterine contrac- 
tions at the moment when the tissues are stretched to the utmost limit. In 
such an event the tear occurs either by the perineal muscles contracting 
powerfully in order to meet the emergency, or from their inability, in con- 
sequence of long over-distention, to contract at all. Nor must we ignore 
the form of the perineum. There are congenital peculiarities which exert 
an influence on the mechanism of labor, greatly complicating the process, 
as, for instance, a redundancy of perineal tissues with a straight sacrum. 
This vice of organization favors the direct protrusion of the presenting part, 
instead of deflecting it in the axis of the proper curve. Under this head 
may also be noticed a preternatural narrowing of the pubic arch, interfering 
with the movement of extension, and thus rendering it necessary that the 
stretching of the perineum should be inordinately great to admit of the 
passage of the head. LACERATIONS OF THE PERINEUM. 
727 
Under the second head among the most conspicuous causes of laceration 
are unusual size of the foetal head and unusual breadth of the foetal shoulders 
or hips, requiring for their extrusion an excessive extension of the vaginal 
outlet. It is possible for the head to escape without harm to the perineum, 
and yet for the latter to be torn by the shoulders which follow. 
Instruments constitute the third cause of the accident, and in unskillful 
hands are capable of doing incalculable mischief. If a child is pulled through 
the maternal passages by the forceps without regard to the curves of the 
pelvis, or if the instrument is used regardless of the principle of the lever, 
or if the accoucheur allows himself to be surprised by the sudden expulsion 
of the head and forceps together, there is no doubt that a rupture will be 
likely to happen. In wise and practiced hands, however, I regard instru- 
ments as among the most valued resources of the obstetric art, and capable 
of preventing the very damage which they are frequently charged with pro- 
ducing. 
Besides the causes which are immediately connected with parturition, lacer- 
ation of the perineum may be occasioned by falls upon pointed bodies, or 
by the extraction of large tumors through the vagina. I have seen this 
occur during the removal of an enormous fibroid. 
Varieties.-There are four degrees of lacerated perineum : first, where 
the laceration extends from the posterior commissure, stopping short of the 
perineal centre; second, where the laceration reaches the verge of the anus, 
including the skin and subcutaneous cellular tissue, but not the sphincter 
muscles; third, where the rupture extends into the rectum, involving the 
sphincter vaginae and the superficial sphincter ani muscles; fourth, where the 
rupture extends not only through the sphincter of the bowel, but also into 
the recto-vaginal septum. A fifth variety has been noticed, in which the 
head passes directly through the perineal centre, leaving the sphincter of the 
vagina and the sphincter of the bowel untorn. This, however, must be an 
exceedingly rare injury. 
Results of Laceration.-The evil effects of laceration of the perineum 
will depend on the degree of rupture. When only the posterior commissure 
is severed, a very common accident, little or no inconvenience follows. If, 
however, the rent extends beyond this, no matter how small the degree, evil 
almost invariably follows. When the rupture reaches the margin of the 
anus, the uterus loses an important support. The utero-sacral ligament 
yields, and the organ descends, giving rise to prolapse or procidentia. In 
addition to this, the posterior wall of the bladder and the anterior wall of 
the rectum are apt to protrude. The effects of these several displacements 
are a sense of dragging, weight, and weariness about the loins, incapacity 
for walking or standing, irritability of the bladder, and often indigestion, 
with disturbance of the nervous system. When the rupture extends through 
the sphincter muscle of the bowel, there follows a kind of disability infinitely 
more serious than those already named. All control over the intestinal con- 
tents is lost, faeces and gas passing involuntarily; the person and clothing 
of the patient are constantly soiled and rendered offensive by the escape 
of the contents of the bowel. The mortification caused to a sensitive mind 
by an infirmity of this nature is exceedingly great, and is often instrumental 
in driving the unfortunate sufferer into seclusion. I know of no surgical 
achievement which brings greater satisfaction to an operator than the suc- 
cessful restoration of a lacerated perineum, rescuing a patient from such an 
infirmity, and restoring her to the society of her friends. 
Changes following Laceration.-Slight lacerations appear only to in- 
crease the antero-posterior extent of the vulva, but when the sphincter 
muscles are severed the deformity resulting is quite conspicuous. The pos- 
terior extremities of the greater labia are drawn asunder by the retraction of 
the transverse perineal muscles, and turned upward by the sphincter vaginae 
and the anterior fibres of the levator ani. When the recto-vaginal septum is 
torn, the mucous membrane of the bowel will project both forward into the 728 
SURGICAL DISEASES OF WOMEN. 
vagina and downward, as in prolapse of the bowel. On the completion of 
cicatrization the chasm is somewhat lessened, though the appearances are 
not materially changed. 
Time of Operating.-With regard to the proper time there has been no 
small difference of opinion among writers, some advocating primary and 
others secondary operations. By primary operations are meant those done 
at' the time of the accident, when the surfaces are raw; by secondary opera- 
tions, those which are undertaken after cicatrization has been completed and 
the tissues have become sound. I shall not enter into any discussion on this 
point. Whenever an accident of this nature occurs to an obstetrician, and 
the rent does not include the sphincter of the bowel, the time to operate is 
immediately after the reception of the injury. The edges of the rent are 
then fresh, and, although exposed to the irritating lochial discharges, if 
neatly approximated they will probably adhere. When, however, the rup- 
ture extends into the rectum, the case should be left until cicatrization and 
consolidation of the fibres are completed, which will require not less than 
two months. 
Method of Operating.-The literature of rupture of the perineum ex- 
hibits a singular want of accord as to the best plan to be pursued in order 
to effect a cure. Celsus had no remedy but to tie the limbs of the patient 
together and enforce rest. Deleurye* affirms that extensive ruptures can 
be cured in this manner. Aitkenf ignores sutures; D'Outrepont, Busch, 
and Moser do the same; and to the same effect are the statements of Paletta,t 
Gardieu,§ Boyer, and Duparcque.|| And to these authorities may be added 
Waller, Blundell, and Davis. Ambrose Pare advises the use of sutures, and 
Mauriceau inculcates a similar practice, though neither, perhaps, ever carried 
his suggestion into effect. The first recorded case of this operation was by 
and among its earlier advocates may be mentioned Moreau, 
Sinellie, De la Motte, Morlanne, Suncerotte, Mayo, Bond, Churchill, Alcock, 
Campbell, Osiander, Williams, Langenbeck, Roger, Dieffenbach, Dupuytren, 
Roux, Chelius, Burns, etc. 
Among British surgeons, the most conspicuous name associated with the 
treatment of laceration of the perineum is that of Baker Brown. The 
chief features of this surgeon's operation were extensive denudation, the use 
of quilled alternated with interrupted sutures, and division of the sphincter 
ani on each side. Since the introduction of the silver thread by Sims, the 
operation by suture may be regarded as a very successful one. The first to 
use metallic sutures in the treatment of this injury was Dr. Mettauer,** of 
Virginia, in 1830. The substance employed was lead 'wire. 
Operation.-In primary operations the parts are to be brought together 
by silver sutures, which should include the tissues to the full depth of the 
rupture. They should be allowed to remain seven or eight days before being 
removed. The number of the sutures will be determined by the extent of 
the rupture. They should not be more than three-eighths of an inch apart. 
The tissues are flaccid, without elasticity, and exert very little strain on the 
stitches. The parts are to be kept clean and free from the vaginal discharges 
by a stream of water colored with a solution of permanganate of potash and 
applied morning and evening by means of a syringe. 
In secondary operations, the treatment will include a period of preparation, 
the operation, and the after-management. 
Preparation.-When the attention of the surgeon is first invited to a case 
of rupture of the perineum, the patient will frequently be found suffering 
from diarrhoea, indigestion, and a train of distressing nervous symptoms, 
* Traite des Aocouchements, p. 134. 
t Principles of Midwifery, 1788. 
J Exercitationes Pathologic®, pars ii., Mediolani, 1826. 
3 Trait€ complet des Accouchements, tome iii. 
|j Histoire complete des Ruptures et des Dechirures de I'UtSrus, du Vagin et du PSrinee. 
Guillemeau's Surgery, chapter viii. p. 354. 
** American Journal of the Medical Sciences, 1850, vol. xx. p. 329. LACERATIONS OF THE PERINEUM. 
729 
many of which have been aggravated by the reprehensible practice of ad- 
ministering regularly laudanum and other narcotics. To correct the intes- 
tinal disturbance, the diet should be carefully regulated, allowing meat, milk, 
rice, and stale bread, with very few vegetables. 
The bed on which the patient is to lie should be a firm hair mattress, 
protected by a piece of rubber-cloth, over which is to be placed a folded 
sheet. The evening previous to the operation the bowels must be opened by 
a gentle laxative, followed by twenty drops of laudanum. For the satisfac- 
tory execution of the work, four assistants will be required,-one to take 
charge of the anaesthetic, one to support each limb, and one to attend to the 
sponges, the handing of instruments, etc. The position best adapted to the 
operation is on the back, across the bed, the hips projecting over its side, the 
limbs flexed on the body and separated. 
The instruments required are a keen-edged scalpel (Fig. 1433), a pair of 
rat-toothed forceps (Fig. 1434), a pair of scissors slightly curved on the flat 
(Fig. 1435), a long needle with the eye near its extremity, and mounted on 
a handle (Fig. 1436), some iron and silver wire, a few shot, and a shot-com- 
pressor. (Fig. 1437.) 
Fig. 1433. 
Fig. 1434. 
Fig. 1435. 
Fig. 1436. 
Fig. 14.37. 
Scalpel. 
Forceps. 
Scissors. 
Needle. 
Shot-compressor. 
The patient being placed in the lithotomy position, as described above, the 
operator, with a keen-edged scalpel, and sitting in front of the perineum, 
commences the denudation of the sides of the laceration. This must extend 
inward sufficiently far to include a very little of the mucous membrane of 
the vagina, outward towards the buttock, and upward, so as to include a por- 730 
SURGICAL DISEASES OF WOMEN. 
tion of the base of each labium. The entire breadth of the freshened surface 
must not be less than one inch, or one inch and a quarter. In depth it is 
only necessary to remove the thinnest possible film of tissue,-not more than 
is requisite to secure a bleeding surface. To go deeper than this is useless, 
besides causing an unnecessary and possibly troublesome loss of blood. The 
vivified surfaces should be as near alike on the two sides as possible, and 
must join at their anal extremity. The work of denudation may be facili- 
tated by an assistant keeping the parts on the stretch. 
When the sphincters have been torn, or when the rent involves, in addition, 
the recto-vaginal septum, the latter will also require to be freshened for at 
least half an inch upward on its vaginal surface. This will be facilitated by 
the operator placing his finger in the rectum and stretching over it the septum, 
the mucous surface of which can then readily be denuded by the curved 
scissors; or the same end can be attained by allowing the finger of an as- 
sistant to take the place of that of the operator, while the latter, with the 
forceps, picks up the mucous membrane and shaves off a thin film with the 
bistoury. (Fig. 1438.) Some surgeons employ exclusively the sharp-pointed 
Fig. 1438. 
Surfaces denuded. 
scissors, the blades somewhat curved, for the purpose of securing a raw 
surface. The parts are rendered tense by two digits inserted into the 
rectum, while the labia are at the same time put upon the stretch by the 
fingers of assistants. A small opening is made between the mucous mem- 
brane and the underlying connective tissue, into which are thrust the blades 
of the scissors, and the dissection effected, submucous and subcutaneous. 
Dr. Albert Smith uses for this purpose, and much in the same way, a dart- 
shaped knife. The same operator has succeeded in establishing a raw surface 
by the burr of the surgical engine revolving at a very rapid rate. Person- 
ally, I prefer an ordinary keen-edged scalpel for the denudation, exchanging 
it now and then for the scissors. 
The bleeding is rarely sufficiently copious to demand the use of a ligature: 
any vessel which continues to bleed should be treated by torsion. Obstinate 
oozing which does not subside on the application of a stream of cold water 
from a syringe can be promptly subdued by applying to the raw surface a 
napkin wet in very hot water. 
Introduction of sutures.-The approximation of the edges of the wound is 
now to be effected by metallic sutures, which are to be introduced, the first LACERATIONS OF THE PERINEUM. 
731 
at the posterior or anal extremity of the laceration, and the others in their 
regular order forward. 
The first suture is the most important one; indeed, on its proper disposition 
depends the success of the operation. As it should include a considerable 
extent of tissue and is placed on some strain, I prefer for the purpose iron 
thread coated with silver. When the sphincters have been torn, the needle is 
entered five-eighths of an inch from the margin of the wound on one side, at 
the anterior part of the ischio-rectal fossa and below the level of the anterior 
wall of the anus, and is carried forward and upward, guided by a finger in 
the rectum, until the point is made to emerge at the middle of the recto- 
vaginal septum, about one-sixteenth of an inch above the junction of the raw 
surface and the mucous membrane. As soon as the eye of the instrument 
becomes visible, it is to be threaded with the iron suture and then withdrawn, 
thus leaving the wire in one side of the rupture. This done, the needle is to 
be detached from the thread and passed unarmed in the same manner through 
the corresponding tissues on the other side, its point coming out near to or 
at the opening made by the instrument in the septum at its first passage. 
The vaginal end of the wire is now passed through the eye of the needle; as 
the latter is withdrawn the suture makes the entire circuit of the wound. 
The second thread is to be inserted about three-eighths of an inch anterior 
to the first, except where it appears on the septum, which should not be over 
a quarter of an inch above the preceding wire. The remaining sutures, con- 
sisting of stout silver wire, seldom more than two or three being required, 
are next to be passed across the w'ound, entering and coming out three- 
quarters of an inch from the margins of the freshened surfaces and barely 
including the mucous membrane of the vulva, and then crossed from side to 
side. (Fig. 1439.) 
The ends of each suture on being introduced are to be passed through a 
perforated shot, bent, and twisted round, so as not to become separated. 
Closure.-All blood-clots being sponged away, the surgeon untwists the 
ends of the posterior wire in order to liberate the shot, and the sides of the 
opening are brought together much in the same way as the cord of a purse 
or satchel puckers up the orifice which it surrounds. The adjustment will 
be facilitated by an assistant pressing at the same time the sides of the nates 
towards each other. As soon as the operator is assured that the denuded 
surfaces are in contact, the shot is to be run down and clamped on the wire 
by the compressing forceps. Each suture in turn is to be tightened and 
secured in the same manner; after which the wires should be cut off on a 
level with the surface of the shot. (Fig. 1440.) At one time, following in 
Fig. 1439. 
Fig. 1440. 
Surfaces denuded and sutures in position. 
The laceration closed. 
the track of other surgeons, I was in the habit of inserting between these 
primary deep sutures superficial metallic ones with an ordinary needle; but for 
several years, convinced of theii' uselessness, I have abandoned the practice. 732 
SURGICAL DISEASES OF WOMEN. 
The urine being drawn and the knees tied together, the woman is now put 
to bed, the position on the back being preferable for the first few hours, after 
which she may be changed to either side as may be most comfortable. 
After-Treatment.-For the first four days the bowels must be kept quiet, 
and for this object half a grain of opium in pill may be given three times 
a day for one or two days. After this period a teaspoonful of compound 
liquorice powder, taken at bedtime every second night, will secure a soft 
passage the following morning; after which the perineum must be washed 
with a stream of tepid water projected from an ordinary syringe. If the 
bowels are kept confined until after the sutures are taken away, which is a 
common practice and one which I formerly approved of, the rectum fre- 
quently becomes impacted with hard fecal accumulations, the extraction of 
which seriously endangers the soft bond of union between the edges of the 
wound. The urine should be drawn morning and evening, or oftener if the 
state of the bladder demands it. Catheterization after an operation for rup- 
tured perineum can be most conveniently accomplished with the patient on 
the side with the limbs well drawn up. When the physician is at a distance, 
rendering it inconvenient to make more than a single daily visit, and the nurse 
is incompetent to use the instrument, the self-retaining catheter of Sims can 
be worn. After four days the patient may be allowed to pass the urine volun- 
tarily, a bed-pan being placed under the hips to receive the secretion. Before 
removing the pan it is well to take the precaution to introduce the nozzle of a 
gravity douche into the vagina and drench the parts with a solution of per- 
manganate of potash or with tepid water, so that the wound may be freed 
from the irritation of the urine. After the third day, a piece of soft linen 
spread with benzoated oxide of zinc ointment, or with vaseline, laid against 
the surface of the 'wound, will add to the comfort of the patient. 
Patients sometimes suffer greatly with flatulence after the operation : when 
this symptom does not yield to the use of a carminative, a gum catheter 
passed a little distance into the rectum will give exit to the accumulation. 
Nervous restlessness is best controlled by one of the bromides. The diet 
should consist principally of milk, beef-tea, eggs, coffee, chocolate, and bread. 
Removal of stitches.-On the sixth day-never later than the seventh-the 
sutures must be removed, in the reverse order of their insertion. In doing 
this, the hips of the patient must rest on the edge of the bed, and, that the 
threads may be taken away with as little pain as possible, each wire should 
be cut on one side near the shot clamp, then the hook at its end straightened, 
to prevent scratching while drawing it out. During the traction of the wire, 
it is a good plan to make counter-pressure against the loop with the blades 
of the scissors. After the extraction of the sutures, the knees are still to 
remain bound together for four or five days, and at night for as many more. 
On the tenth day the patient may be allowed to sit up, and afterwards 
she may gradually resume her usual duties. 
The quilled sutures, which were employed in the earlier operations of 
Baker Brown, and thirty years earlier by Roux, Dansul, and others, and the 
lateral incisions, are, since the introduction of the metallic thread into sur- 
gery, rarely resorted to. 
When failure follows an operation in a case of laceration extending into 
the rectum, it is usually to be attributed to the imperfect manner in which 
the posterioi1 suture has been applied. The parts have not been properly 
pursed, and the consequence is an opening between the rectum and the 
vagina, which ends in a permanent fistula, rendering a second operation 
necessary, and which, though it may be small, will sometimes resist all at- 
tempts to close it, and will require that the parts be laid open to the original 
extent and their closure commenced anew. 
Malformations of the Vagina. 
Malformations of the vagina are both congenital and acquired. Among 
those which may be noticed as congenital is the double vagina. I have seen MALFORMATIONS OF THE VAGINA. 
733 
a number of examples of this condition. Generally, the partition which forms 
the septum of the canals is placed against the middle of the os uteri, so that 
the latter opening communicates with both vaginae, or there may be a double 
uterus. In one instance I observed that the neck of the uterus was wholly 
in one canal, the other having no connection whatever with the os uteri. 
The lady, who was conscious of something unusual in the construction of 
the parts, and who consulted me in consequence of contemplated marriage, 
appeared much delighted at the prospect of one channel being used without 
the risk of becoming pregnant. The vagina being developed from Muller's 
canals, all its abnormities are the result of the imperfect development of these 
two channels. The vagina occasionally opens into the rectum or the bladder. 
Incomplete Vagina.-The canal of the vagina is sometimes very short, con- 
stituting only a shallow depression, and terminating in a cul-de-sac; or it may 
possess the normal length, and yet end in a blind pouch, without having any 
communication with the os uteri. 
Absence of the Vagina is occasionally met with, where no trace of the canal 
can be seen on the surface of the perineum; and yet in a case of this kind 
which came under my notice the mons veneris was surmounted with an 
unusual growth of hair, and the woman well developed in all other respects, 
and possessed of the usual sexual feelings. A rudimentary uterus, it was 
thought, could be felt by a rectal examination. Entire absence of the vagina 
can be determined only by introducing a catheter into the bladder and a 
finger into the rectum, approximating the two. If the intermediate tissue 
appears to consist only of a thin membranous layer, the absence of the canal 
may be inferred. 
Congenital imperfections of the sexual apparatus are sometimes found as- 
sociated wfith other abnormities of the body. A woman was brought to me 
from Western Pennsylvania for examination. She possessed a strong, mas- 
culine build, was six feet in height, and had a deep, coarse voice. The vagina 
was a mere depression or shallow cleft in the perineum. The uterus appeared 
to be absent; very little hair existed over the pubes; the breasts were rudi- 
mental, and several large hard tumors, apparently malignant in character, 
occupied the cavity of the abdomen. The woman, so far as I could learn, 
had never experienced any sexual desire. 
External Closure.-The entrance to the vagina is sometimes barred by the 
fusion of the labia majora or labia minora, or by a firm hymen. 
Acquired Stenosis and Atresia follow from causes which are either me- 
chanical, chemical, or pathological. Among the mechanical causes, none 
play so important a role as prolonged labor. The long detention of the 
head in the pelvic cavity destroys by pressure the vitality of the mucous 
membrane of the vagina, causing it to slough. The resulting cicatricial 
tissue produces narrowing of the canal, or its surfaces may unite and thus 
obliterate the cavity altogether. Wounds caused by falling on a pointed 
body, which lacerates the walls of the vagina, are likely to be followed by 
serious stenosis of the canal. 
Caustic acids applied to the interior of the vagina are often sufficient to 
produce extensive ulceration, sloughing, and subsequent narrowing or adhe- 
sion of its surfaces. 
Pathological atresia includes all those cases of sloughing which are due to 
syphilis, smallpox, and certain low fevers, as typhus. Stenosis and atresia 
produce evil effects by rendering the canal unfit for coition, parturition, or 
the escape of the menses. 
Treatment.-Generally it may be said that cases of absence of the vagina 
admit of no treatment, as in almost all instances there is also an absence 
of the uterus. Should there be, however, a very short canal, terminating in 734 
SURGICAL DISEASES OF WOMEN. 
a cul-de-sac, and after a careful examination a uterus can be discovered, an 
operation will be proper. 
In making the exploration in search of the uterus in these cases, in order 
that the examination be satisfactory it is necessary that the woman be 
etherized, and placed on her back, with the shoulders and body well flexed 
so as to relax the abdominal parietes. With one or two fingers of one hand in 
the rectum, and those of the other pressing firmly over the hypogastric region, 
the surgeon may be able to feel the uterus. 
Communications between the vagina and the bladder, or between the former 
canal and the rectum, which may exist as a result of either congenital or 
acquired atresia, are to be closed when practicable, as in vesico-vaginal fistula. 
In one case which I presented to the medical class at the Pennsylvania Hos- 
pital, in which a recto-vaginal opening existed with anterior atresia, a cure 
was effected by laying open the parts in the median line and completing the 
vagina anteriorly. 
Stricture.-When the canal is contracted at some part of its course from 
the effects of a circumscribed slough, the coarctation or stenosis is best cor- 
rected by simply dividing the cicatricial tissue with a bistoury, and using a 
certain amount of forcible dilatation by means of graduated cylindrical 
specula or bougies. 
This operation I have frequently repeated in order to obtain room to close 
a vesico-vaginal fistula situated behind the stricture. 
A stricture may also exist from inflammatory deposits in the submucous 
connective tissue of the canal, and interfere both with coition and with par- 
turition. The contraction can be overcome by dilatation with graduated 
bougies, and, if it offers a serious obstacle to the passage of the foetus, may 
be divided by either a subcutaneous or an open incision made during the 
presence of a pain. 
Atresia, when acquired, may be limited to the deep portion of the vagina, 
or it may include almost the entire length of the canal. These are cases 
which demand the utmost care in an operation to avoid opening the bladder 
or the rectum. 
The patient, having been etherized, is placed on her back across the bed, 
with the hips projecting over its edge, and the limbs flexed on the pelvis 
and supported on either side. A sound or staff being now placed in the 
bladder and given to an assistant, the surgeon, with a finger in the rectum, 
carries his dissection cautiously inward, either with a bistoury or with a pair 
of curved scissors, constantly referring to his guides, the sound and the finger, 
to ascertain that he is not wandering from the proper line. Frequently after 
deepening the incision a little distance the finger at certain points may be 
substituted for the scissors or knife in breaking up adhesions, lacerating 
bands, and enlarging the opening, until the neck of the uterus is reached. 
Amussat, in a case of retention of two years' duration, succeeded after dividing 
the skin with a bistoury in working his way to the uterus by using only the 
finger-nails for tearing the tissues. The laceration was effected by three 
operations at intervals of three days. As a rule, the difficulties thicken as the 
neck of the uterus is approached; and, that no hap-hazard cuts be made, it 
has been advised to introduce the fingers well up into the rectum so as 
to grasp the body of the uterus and at the same time force its neck down 
towards the vagina, when it may be recognized by the operator. 
After the operation has been completed, the introduction of plugs or a gum 
bougie, coated with oil or cold cream, becomes necessary to counteract the 
subsequent tendency to closure. 
The fenestrated cylindrical glass or rubber speculum has the advantage 
over other means used for dilatation, in that discharges can escape through 
the opening in the instrument, thereby contributing to the safety of the 
patient. RETAINED MENSES. 
735 
Operations for congenita] atresia should be performed about the period of 
puberty, or before the establishment of the menstrual function. 
Retained Menses. 
One of the great evils resulting from imperforate vagina, whether congen- 
ital or acquired, is the retention of the menstrual secretion. The distension 
of the uterus from an accumulation of this nature, the product of repeated 
menstruation, is sometimes so great as to raise the organ from the pelvis into 
the abdomen, giving the patient the appearance of a woman five or six months 
advanced in pregnancy. When the obstruction is due to an unyielding and 
imperforate hymen, to fusion of the labia, or to a partial occlusion of the va- 
gina, a distinct impulse can be detected, and even a protrusion of the septum 
seen, during coughing or straining efforts. 
Treatment.-The treatment will consist in opening a way for the escape 
of the retained secretion. When a dense hymen constitutes the obstructing 
medium, a crucial incision should be made. If the retention is caused by 
union of the labia, a vertical incision will be required; if by occlusion of 
the vaginal canal, congenital or otherwise, the same course is to be pursued 
as has been described for the relief of atresia. ■ 
Operations of this kind are not unattended with danger. Many cases die 
from subsequent peritonitis, not because of the incisions which are made, or 
from the admission of air to the menstrual fluid and its decomposition giving 
rise to endometritis or pyaemia, but from the escape of a portion of the men- 
strual blood through the Fallopian tube into the abdominal cavity. 
It may appear singular that a Fallopian tube which has resisted any escape 
of fluid from its cavity during the period of its great distention should per- 
mit such an accident after that distention has been removed by an opera- 
tion ; yet there is little doubt that this is the case. The explanation which 
has been given of this apparent paradox is probably the true one, namely, 
that the powerful contraction of the uterus which follows the evacuation of 
its contents drives a certain quantity of the menstrual fluid back into the 
Fallopian tubes, which, in consequence of their walls being overstretched and 
weakened, do not possess the power to resist the additional uterine force, 
and thus allow a portion of their contents to pass through their free extrem- 
ities, or, as has happened, their walls may give way by ulceration the result 
of inflammation. It is not improbable, from some experiments made by 
Matthews Duncan, that portions of the menstrual blood may be forced by 
the contractile power of the uterus through its own tissues and those of the 
Fallopian tubes into the peritoneum without causing any visible lesion, and 
thus give rise to peritonitis. 
To avoid the great risk of extravasation, some advise making a small 
opening or puncture, thus allowing the fluid to drain away slowly. Twice 
I have relieved menstrual accumulations by free incisions, and without any 
ill effects. In one of the cases, that of a patient of Dr. Elwood Wilson, 
of this city, the obstruction originated from a protracted labor, the phy- 
sician allowing the head to remain so long in the vagina without rendering 
instrumental aid that sloughing occurred in nearly the entire length of the 
canal, and this was followed by complete atresia, rendering it necessary to 
divide a long extent of cicatricial tissue. Quite a gallon of a thick, tarry 
fluid was discharged. The othei- case, which was under the care of Dr. Jacob 
Roberts, of Philadelphia, was produced in the same manner, but involved less 
structural damage to the vagina, and was much more recent in its duration. 
After the collection has been evacuated, vaginal injections of warm carbolized 
water, or of permanganate of potash, should be used. The aspirator is a con- 
venient instrument for removing accumulations of this nature in a manner 
which obviates all the objections urged against free incision, preventing the in- 
trusion of air, and effecting the evacuation in a very gradual manner. The 
aspirating trocar, when the obstruction is seated at or near the orifice of the 736 
SURGICAL DISEASES OF WOMEN. 
vagina, can be pushed immediately into the canal; or, when there is complete 
atresia, it may enter the uterus either through the abdominal walls or through 
the rectum. The operation should bo repeated every four or five days, and 
only a few ounces removed at a time. In the very slight and gradual con- 
traction of the uterus which follows may consist the patient's safety. In all 
cases of retained menses, early operations are of vital importance, as likely 
to avoid those dangers which attend old and large accumulations. 
Fissure of the Vagina is seated at the ostium, and almost invariably at the 
posterior part. 
A linear ulcer from one-quarter to three-eighths of an inch in length con- 
stitutes the disease. It is caused usually by laceration of the fourchette in 
delivery. It is often productive of much suffering in urination, defecation, 
and coition, and may develop a troublesome vaginismus, and finally a train of 
very troublesome nervous symptoms. It will disappear under the local use 
of iodoform, rarely requiring incision. 
Ulceration.-Ulcers of the vagina are common, specific, and malignant, and 
must be treated on principles applicable to similar affections in other regions 
of the body. 
Prolapse of the Vagina is rarely seen in young females, but is exceedingly 
common among married women, and not unfrequently is observed in the 
unmarried after middle life. 
It is generally complicated with, indeed is often dependent on, descent of 
the womb, hernia of the bladder or the rectum, or laceration of the perineum. 
The prolapse may involve the whole circumference of the tube, or it may be 
limited to the anterior wall, especially when accompanied by cystocele, or 
the posterior wall alone may protrude, conjoined with a rectocele. 
The prolapse appears as a soft, red or bluish tumor, globular in form, 
with circular wrinkles, projecting from the vulva, and even extending down 
between the thighs. It imposes no small degree of disability. Standing, 
walking, and lifting are followed by uneasiness and weakness. Dragging 
lumbar pains are complained of, and very commonly there is much irrita- 
bility of the bladder. 
There is some resemblance between prolapse of the vagina and prolapse 
of the uterus, cystocele, rectocele, and uterine polypus, (fig. 1441.) 
In procidentia uteri the tu- 
mor is devoid of wrinkles, and 
firm, and the orifice of the 
os can be seen,-appearances 
having little resemblance to 
those characterizing a pro- 
lapsed vagina, which is soft, 
globular, and rugose. 
In cystocele the tumor en- 
larges during the accumula- 
tion of urine, and subsides on 
the passage or withdrawal of 
the contents of the bladder. 
Rectocele can be recognized 
by inserting a finger into the 
rectum, when it can be carried 
forward into the pouched intestine. A polypus is pedunculated, hard, and 
smooth on its surface, and not easily restored into the vagina. 
Treatment.-The treatment for the relief of prolapse is medical, mechan- 
ical, and surgical. 
The medicinal agents employed are large injections of cold water, in which 
should be dissolved some astringent,-alum, tannic acid, common salt, or a 
Fig. 1441. 
Utero-vaginal prolapse, with cystocele and rectocele. TV MORS OF THE VAGINA. 
737 
little Monsel's solution of iron. If the woman is weak and in feeble health, 
the general strength must be improved by enjoining sufficient rest, and the 
use of iron, quinine, and strychnia, and, when circumstances will permit, by 
sea-bathing and carriage-riding. 
The mechanical treatment consists in reducing the prolapsed vagina, and 
retaining it in place by a lever pessary. The ring and ball pessaries will also 
furnish the necessary support, but they have the disadvantage of keeping 
the canal dilated. Sometimes no contrivance will prevent the descent of the 
vagina except a stem pessary. (See Procidentia Uteri for these different 
pessaries.) 
When the prolapse depends on the existence of a ruptured perineum, no 
mechanical appliance can be used with advantage until the laceration is 
closed. 
The surgical management of prolapse of the vagina must be determined 
by the degree of displacement. It may be sufficient to freshen a portion 
of the opposing surfaces of the labia majora and unite them by sutures,- 
an operation to which the name of episiorrhaphy has been given. I have 
resorted to this plan several times with marked relief. When the prolapse 
is utero-vaginal, or cysto-vaginal, or recto-vaginal, it may be necesssary to 
narrow the cavity of the vagina (see Elytrorrhaphy) in order to secure the 
needful support. 
Tumors of the Vagina are quite uncommon. Those which have been 
observed are the cystic, the fibrous, and the papillomatous. 
Cystic tumors originate in one of the mucous follicles of the canal, the walls 
of which become distended and thickened, and contain a ropy, viscid se- 
cretion. These growths are sometimes multiple or in clusters; they rarely 
attain any great size, and have an elastic feel, and a smooth, almost polished 
surface. Incision of the sac effects a cure. 
Fibrous tumors are formed in the submucous connective tissue of the canal, 
attain considerable size, and differ from similar growths elsewhere in being 
less dense and compact in their structure. They often grow to the size of a 
marble and then remain quiescent. In this condition, unless attended with 
pain, it is better not to interfere, but when their growth is progressive they 
should be laid open and enucleated. 
Papillomata are sometimes met with in the vagina primarily, but oftener 
as secondary to the like disease of the neck of the womb. These growths, 
which consist of hypertrophied papillae, simple or compound, and covered 
with epithelium, present a villous appearance. They are richly supplied 
with blood-vessels, and bleed profusely when rudely handled. Excision 
and cauterization with the acid nitrate of mercury suffice for their eradi- 
cation. 
Epithelioma is rarely seen in the vagina earlier than the fortieth year, and 
in a large majority of instances it occurs in women who have borne children. 
The disease appears at first as a wart-like excrescence, and as it progresses 
forms exuberant cauliflower-like granulations covered with pavement epi- 
thelium. These growths ulcerate, break down, and furnish a foul sanious 
discharge, which irritates the surrounding parts, and tends to implicate the 
sacral, iliac, and lumbar glands which receive the lymphatics of the vagina. 
Epithelioma in its progress is attended with much suffering, wThich, with the 
contamination of the blood, wears the patient out in the course of one or 
two years. 
When discovered very early and the disease is quite limited, it should be 
excised and the surface cauterized with the thermo-cautery. 
Rodent ulcers have been observed in the vagina, and might be confounded 
with epithelioma. The absence, however, of cauliflower excrescences, the 
freedom of the glands from contamination, and the tardy progress of the 
disease would suffice to distinguish it from epithelioma. The remedy 
excision. 
vol. ii.-47 738 
SURGICAL DISEASES OF WOMEN. 
Gonorrhoea. 
Gonorrhcea in the female differs from that in the male. In the former the 
urethra generally escapes the infective inflammation, the parts affected being 
the vulva and the vagina. The disease may also extend into the uterus, and 
thence even to the Fallopian tubes and the ovaries. 
The period which elapses between impure connection and the development 
of a gonorrhoeal vulvitis and vaginitis does not differ materially from that in 
the male. 
Symptoms.-The disease is ushered in by heat, itching, smarting of the 
vulva and vagina, and a feeling of weight in the perineum. The parts be- 
come swollen and sensitive, and are soon covered with a profuse muco-puru- 
lent discharge, which as it flows from the inflamed surfaces often causes 
excoriation of the surrounding parts. Though there is frequently consider- 
able smarting during the passage of the urine, it is not occasioned by its 
contact with an inflamed urethra, but by the water dribbling over the ex- 
ternal genitalia, which are congested or inflamed. Sometimes the discharge 
instead of having the consistency of a purulent fluid is tough and stringy 
and adheres tenaciously to the diseased mucous membrane. As in males, 
so in females, when the attack is one of more than common severity, there 
will often be experienced a sense of great fullness deeply seated in the peri- 
neum, and accompanied with pains extending into the groins, down the 
thighs, or into the small of the back. The inguinal lymphatic glands are 
also frequently enlarged. When the inflammation travels upward and im- 
plicates the womb, there will be found the usual purulent discharge filling up 
and escaping from the mouth of the organ, modified somewhat by the mucus 
derived from the glands of the cervix uteri, which imparts to the fluid a 
tangled, ropy consistency, rendering it sometimes difficult to dislodge it from 
the os. 
Diagnosis.-It is often a delicate as well as a difficult matter to dif- 
ferentiate the discharge of gonorrhoea from that arising from other causes, 
especially leucorrhoea. Indeed, in many instances it would be unsafe to give 
other than a very guarded diagnosis. The character of many women, and 
the peace of many households, have been most unjustly damaged by med- 
ical opinions couched in language which conveys the idea of suspicion. Gen- 
erally, however, there is in leucorrhoea a less fiery redness of the mucous 
membrane of the vagina than in gonorrhoea; there is also an absence of 
smarting during and after micturition; the lymphatic glands are not in- 
volved ; the inflammation, moreover, does not extend to the external geni- 
talia, as the nymphse, labia, and clitoris; nor do the abrasions or excoriations 
and the pain which so commonly belong to gonorrhoea exist in leucorrhoea. 
These characteristics, in conjunction with the known character of the party 
whose purity may be suspected, will contribute somewhat to the solution 
of a doubtful question. Many women suffer innocently from chronic gonor- 
rhoea, contracted from a husband who labored under a slight gleety dis- 
charge at the time of their marriage. The latent gonorrhoea spoken of by 
Noeggerath as so common among married women, he attributes to the bus- 
bands having had at one time a specific urethritis. The statements of this 
author are entirely too sweeping. The mere fact of a man having had a 
gonorrhoea in the past does not render it probable that his wife will suffer 
from the disease, unless he still labors under a urethral discharge at the time 
of marriage. 
Discharges from the vagina are frequently observed even in young 
children, and I have known mothers to suffer the greatest mental distress 
under the impression that their children had been the subjects of impure 
approaches. 
Treatment.-Except in cases where the inflammation has entered the 
urethra, the treatment of gonorrhoea in the female is a purely local one. At 
'* the beginning of an attack the patient should be confined to bed, a gentle GONORRHOEA. 
739 
saline cathartic administered, and the diet restricted to the simplest and 
least stimulating articles of food (as bread, milk, tea, and light broths). 
The vagina should be washed out with a syringe or a gentle douche, two or 
three times a day during the first two or three days, with warm chamomile 
tea, passing a gallon of the fluid at each ablution. The next step consists m 
medicating the inflamed surfaces with injections of sulphate of zinc or of 
copper. The surfaces should be kept apart, so as not to come in contact and 
consequently maintain the inflammation by repeating the inoculation through 
the muco-purulent discharges which they furnish. For the purpose of medi- 
cation and to preserve the separation of the vaginal walls, I have employed 
for a long time lint saturated with a solution of sulphate of zinc, at first of 
the strength of four grains and finally of fifteen grains to the ounce of water. 
The lint should be cut in a single long strip, and introduced into the vagina 
through a speculum, packing first the deep part of the canal, and afterwards 
the anterior part as the instrument is withdrawn. This packing may be 
allowed to remain eight hours, when it can be removed by the patient seizing 
the end which lies in the vulva and drawing the strip gradually away. A 
few applications of the lint, made once in twenty-four hours, will soon subdue 
the inflammation and suppuration. Dr. John Black, of New Castle, Dela- 
ware, while a resident physician at the Philadelphia Hospital, employed 
with considerable success vaginal suppositories, after the plan of Sir James 
Simpson, composed of alum, persulphate of iron, tannin, etc. When the in- 
flammation involves the urethra, the latter should be wiped by a little mop 
of absorbent cotton, well soaked in a solution of sulphate of zinc (six grains 
of the salt to two ounces of water), and carried along the canal, held in the 
grasp of a pair of forceps. The application may also be made through the 
urethral speculum. Internally balsam of copaiba acts with the same efficiency 
as in the male, and ranks among the most valuable of our remedies for specific 
urethritis. 
Complications.-Many complications are found to follow specific vaginitis. 
Among them may be named bubo, abscess, vulvo-vaginal adenitis, mucous 
patches, endometritis, inflammation of the Fallopian tubes and ovaries, perito- 
nitis, pelvic cellulitis, and cystitis. 
Inflammation of the inguinal glands is rarely witnessed unless the urethra 
has been implicated in the disease, and must be managed on the same general 
principles as gonorrhoeal adenitis in the male, namely, by leeching, blistering, 
anodyne lotions, painting the glands with compound solution of iodine, or 
rubbing into them an ointment of iodoform. If resolution cannot be ob- 
tained, suppuration should be encouraged by flaxseed-meal poultices, and the 
pus evacuated by a free incision as soon as fluctuation can be discerned. 
Abscess.-When the inflammation extends into the connective tissue un- 
derlying the mucous membrane, vulvar abscess is liable to follow, and will 
declare itself by pain, redness, throbbing, swelling, and pointing, the summit 
of the latter presenting a purple discoloration. Poultices until the abscess 
matures, and evacuation with a bistoury, constitute the treatment required. 
Vulvo-vaginal adenitis, first noticed by Salmons, though regarded as common 
by this writer, is in my experience quite uncommon, and when present rarely 
passes on to suppuration. The enlargement of the vulvo-vaginal glands is 
accompanied by the presence of a considerable induration, discoverable by 
the touch, on either side of the vagina, and also by undue prominence of the 
nymphee. 
The treatment will be the same as that proper in cases of inflammation of 
these glands from causes other than specific. 
Mucous patches are to be removed by the constant use of astringent and 
absorbent powders, as tannic acid or persulphate of iron, or by touching these 
vegetations with a little nitric acid or acid nitrate of mercury, at the same 
time keeping the mucous surfaces asunder by the interposition of soft lint or 
absorbent cotton. 
Inflammation of the Fallopian tubes'and ovaries results from an extension of SURGICAL DISEASES OF WOMEN. 
the inflammation by continuity of structure, and is to be treated by rest, 
gentle cathartics, warm vaginal douches, and opium suppositories to allay 
pain when present. When there is much local tenderness elicited by pressure 
made on the surface of the abdomen above the inflamed organ, leeches fol- 
lowed by hot poultices will be indicated. 
Endometritis.-Inflammation in the cervix uteri or abrasion of its sur- 
face yields to the use of the solid stick of nitrate of silver. There is too 
much risk, however, in intra-uterine injections to warrant their use in medi- 
cating the cavity of the organ; but when the disease does not subside on the 
cure of the vaginitis, the mop must be passed into the organ (which can be 
safely done by dilating the cervix) charged with a weak solution of nitrate 
of silver,-from two to four grains of the salt to an ounce of distilled water, 
-or carbolic acid one part and glycerin ten parts may be employed in the 
same way. 
Peritonitis sometimes, though rarely, occurs, and will require the usual 
treatment,-leeching over the abdomen, blistering, hot poultices, and opium. 
Pelvic cellulitis may be caused by an extension of inflammation from the 
vulvo-vaginal glands, and is a very dangerous complication. Much will 
depend on an early recognition of the inflammation, and its resolution by 
antiphlogistic remedies; or, in case suppuration occurs, the immediate evacu- 
ation of the pus by puncture when this is feasible. 
Cystitis in the female as a sequel of gonorrhoea is a more manageable disease 
than in the male. The internal use of copaiba, and of diluents containing a 
small amount of carbonate of soda, constitutes the best treatment. 
Granular vaginitis.-A form of vaginitis first pointed out by Ricord has 
been described under different names by Deville, Guermand, and others as 
glandular, papular, or follicular vaginitis. There is a difference among writers 
as to its true pathology, some regarding it as an inflammatory hypertrophy 
of the muciparous glands of the vagina, while others believe it to be a sim- 
ilar enlargement of the normal papillee of the mucous membrane of the canal. 
The latter view coincides with my own, though I have had an opportunity 
of observing only a limited number of such cases. 
The disease appears in the form of small, round granulations, the size of a 
mustard-seed, scattered over the vaginal mucous membrane, and occupying 
also the cervix uteri. It is generally met with during pregnancy, and is 
often accompanied with pruritus of the vulva. The appropriate remedies 
are the same as those employed for the treatment of specific vaginitis. 
The disease subsides spontaneously after parturition. 
Vesico-Vaginal Fistula. 
There is one accident liable to occur to the female during the exercise of 
the highest function of her sex, which until a comparatively recent period 
doomed her to a life of seclusion and despondency, rendered the less en- 
durable by her being compelled to live, however isolated, in an atmosphere 
loaded with the volatile products of the urinary secretion. Such was the 
fate of a woman unfortunate enough to suffer from vesico-vaginal fistula, 
until American surgery achieved the conquest of the horrible infirmity. 
Before the discovery of the forceps, vesico-vaginal fistula must have been 
very common, though very little allusion is made to the subject in the medi- 
cal and surgical treatises of the time. Hippocrates alludes to cases in which 
after protracted labor the urine escaped from the vagina, but has no remedy 
to suggest other than attention to cleanliness. Mauriceau, who wrote in 
1714, in speaking of these fistula), intimates that unless they heal sponta- 
neously in the course of two or three months they are incurable. Hoffman 
describes the manner in which these lesions of the bladder occur, but men- 
tions no operation for their cure. The works of Astruc, who in 1776 held 
the important position of physician to the King of France, do not contain 
•a single sentence on the subject. Smellie, whose work was published the VESICO-VAGINAL FISTULA 
741 
same year, speaks of an operation which had been performed for the cure of 
this fistula, but in language which clearly indicates that no success had been 
obtained. Burns, in his treatise on midwifery, has only the palliative remedy 
of the catheter to suggest as a means of relief. Conquest, in his book pub- 
lished the same year as the American edition of Burns by James, 1820, 
strongly urges the propriety of attempting a cure by operation, though no 
plan is described, nor does he lead us to believe that he had ever seen a 
single cure accomplished. 
James, professor of obstetrics in the University of Pennsylvania, in his 
"System of Midwifery," published in 1813, speaking of vcsico-vaginal fistula, 
bases the hope of a cure on the use of an elastic catheter, caustics, and 
vivifying the edges of the opening by the knife. He mentions no cures. 
Ashwell, a prominent writer in London, as late as 1828, makes no allusion 
whatever to this fistula. Gooch, in 1831, mentions a case which was cured 
by using as an obturator a gum bottle with a sponge attached, which was 
adjusted in the vagina in such a manner as to keep the sponge applied to 
the fistulous opening. Other instances of cures were reported by Lalle- 
mand, Vidal, and others, but Velpeau denies their verity. His opinion was 
doubtless shared by others; for the same year in wThich these recoveries were 
recorded, 1834, Blundell in his work summarily disposes of the accident in 
the following language: " A slough of the vagina may lay open the bladder;" 
while Ramsbotham, writing seven years later, 1841, does not speak of the fis- 
tula at all. Davis, while he briefly describes the manner in which the blad- 
der is opened, concludes by saying that " it is a universal fact that the opening 
never does heal." Dewees makes no mention of the fistula, and Churchill 
introduces the subject only to say that all such accidents are hopeless. As 
late as 1866, Simpson, in speaking of sloughing of the vesico-vaginal septum, 
consigns the resulting perforation to the domain of incurable fistula. 
If we turn from obstetrical to surgical writers, the result is the same. 
Ambrose Pare, while he discusses the different kinds of fistulae, does not 
name the vesico-vaginal variety, and Heistei* refers to it only to pronounce 
it incurable. Liston condemns all operations for the cure of this affection as 
useless, or, rather, worse than useless; for he says virtually that all such 
attempts only serve to convert a small opening into a larger one. Earle and 
Laurence speak of a successful operation as being impracticable; and to the 
same effect is the testimony of Chelius, Miller, and Velpeau. Pirrie ignores 
the subject entirely in his Surgery, as also do Dorsey and Gibson. Dupuytren 
and Desault speak only of palliative measures. Earle, after thirty attempts, 
succeeded in effecting a single cure. In 1839 and 1840, Dr. Hayward, of 
Boston, Massachusetts, succeeded in making three cures in twenty opera- 
tions. In 1847, Professor Pancoast reported two cases of vesico-vaginal 
fistula which he had succeeded in closing by a tongue and grooved incision, 
brought together with silk threads. In the same year, Dr. Mettauer, of 
Virginia, published a cure in which the parts had been closed by leaden 
threads. 
In 1852, Dr. J. Marion Sims, at that time residing in Montgomery, Ala- 
bama, placed before the profession the results of his labors in the treatment 
of vesico-vaginal fistula, by which the operation wTas removed from the 
region of uncertainty, and for which the world owes him a debt of eternal 
gratitude. 
The peculiarities which characterized the method of Sims were: first, the 
enlargement and exposure of the cavity of the vagina, rendering the fistulous 
opening accessible, by the use of the duck-billed speculum; second, the use 
of a silver suture which would hold the parts securely together, and for a 
sufficient length of time to procure their union, without disturbing the 
healing by undue irritation or ulceration; third, the employment of a self- 
retaining catheter, thus keeping the bladder drained, and the wound pro- 
tected from contact with the urine. It is true that Chelius and Walter had 
each employed a blunt hook for expanding the vagina; and it is true that 742 
SURGICAL DISEASES OF WOMEN. 
all the methods of treatment outlined in the above indications had been 
employed; but they had never been employed in a systematic manner. For 
example, the position on the hands and knees, or on the abdomen, was the one 
adopted by Wutzcr, Chelius, and Metzler. In 1829, Levert, of Alabama, had 
used silver wire; Gosset, of London, in 1834, had employed gilded wire, and 
Deybcr and Mettauer, of Virginia, leaden wire. The necessity for the cath- 
eter in the treatment of this fistula was known to Volter, of Wurtemberg, as 
early as 1770, also to Gosset, Metzler, and Mettauer. Yet the honor and merit 
of improving, modifying, and combining into a consistent and practical system 
the crude and disjointed materials of his predecessors belong only to Sims. 
Causes.-The causes of vesico-vaginal fistula are mechanical, pathological, 
and traumatic. 
Mechanical.-Under this head may be enumerated badly-fitting pessaries, 
or pessaries which, either from corrosion or from the deposition of the salts 
of the urine, have by their rough and irregular surfaces provoked ulceration 
of the vesico-vaginal septum, instances of this kind are noticed by Beirards, 
Lisfranc, Dupuytren, and Desormeaux. 
In the same manner foreign bodies, as stone in the bladder, in consequence 
of their magnitude and irregular surface, may provoke ulceration and find 
their way into the vagina, leaving a fistulous opening. Twice have I known 
this to occur. 
Pathological.-Carcinoma of the neck of the uterus not unfrequently ex- 
tends to the vagina, bladder, or rectum, destroying their partition-walls, and 
converting these organs into a common cavity. 
Phagedamic chancre I have twice seen produce the same result. 
Traumatic.-Wounds of the vesico-vaginal septum terminating in fistula 
follow both the legitimate and the criminal use of instruments. The mal- 
adroit use of the vectis in attempts to rectify a vicious position of the foetal 
head, or of the perforator in performing craniotomy, may cause this accident, 
as these instruments are liable to slip and open the bladder. Even the for- 
ceps have been charged with playing an important part in producing lesions 
of the vesico-vaginal septum, though on very insufficient evidence. For my 
part, I know of no means so well calculated to prevent the accident as the 
timely employment of this instrument in skillful hands. The bladder may 
also be opened during operations for relieving atresia of the vagina. 
The accident sometimes follows the criminal use of instruments by per- 
sons who are engaged in the nefarious practice of abortion. 
Pressure of the foetal head is the most common cause of vesico-vaginal 
fistula?. My own inquiries into this subject lead me to believe that ninety 
per cent, of these lesions are to be attributed to this cause and occur in first 
labors. Denman long ago recognized pressure as a fruitful source of this 
affection. Simpson reiterates the same fact, and at the same time vindicates 
the forceps from the charge of producing the injury by saying that if the de- 
struction of the septum were due to the employment of this instrument 
it would occur at once, whereas, as is generally known, it is only after 
several following labors that the opening appears. Smellie, Churchill, Hodge, 
Meigs, Penrose, Wilson, Sims, Bozeman, and others bear testimony to the 
same effect. 
The manner in which the pressure acts, causing the destruction of a 
portion of the wall between the bladder and the vagina, is quite clear. The 
foetal head when engaged in the pelvis presses the anterior wall of the vagina 
against the posterior face of the pubic bones, and if from uterine inertia, or 
from a disproportion between the diameters of the pelvis and the head of the 
child, the latter is too long delayed in its passage, the vitality of the pinched 
or pressed tissues is destroyed, a slough in the course of from six to ten days 
drops out, and the fistula is established. The difference in the length of time 
between the labor and the formation of the unnatural opening depends on 
the intensity and the duration of the pressure. Thus, it may be merely 
sufficient to produce ulcerative perforation, or it may be so protracted as to VESICO-VAGINAL FISTULA. 
743 
destroy the vitality of the parts and induce a slough. In the last condition 
the fistula will seldom be delayed beyond four or five days. 
Classification.-There are three varieties of the fistula under considera- 
tion,-viz., uretliro-vaginal, vesico-vaginal, and vesico-utero-vaginal. In the first 
the opening is in the posterior wall of the urethra; in a few cases the entire 
wall of the canal has disappeared. 
In the second variety the fistula may be at the neck of the bladder, at its 
bas-fond, and in rare instances the septum is completely destroyed. 
The relative frequency of the fistula, according to my own observation, is, 
first, at the trigone vesicae, or neck of the bladder; secondly, at the bas-fond ; 
thirdly, in the urethra. 
In the third and least frequent variety the opening exists between the 
vagina, uterus, and bladder. 
Shape, Direction, and Size.-The forms of vesico-vaginal fistula differ 
very much, being oval, round, or elliptical, running in a transverse, lon- 
gitudinal, or oblique direction, and varying in size from an opening not larger 
than a quill to one involving the entire septum. 
Symptoms.-The recognition of a vesico-vaginal fistula is attended with 
little difficulty. If the patient is interrogated, it will be ascertained that 
there is a history of retention of urine following the labor, necessitating the 
use of the catheter, and that in a few days the urine was found to pass away 
involuntarily. The secretion, flowing over the nates, occasions excoriation, 
accompanied by pustules, while the vagina and the external genitalia are often 
found incrusted by the saline matter of the urine, a urinous odor constantly 
emanating from the clothing and person of the patient. It is only, however, 
by a physical exploration of the vagina that the existence of a fistula can be 
certainly determined. In order to make such an examination, the woman 
should be placed on her side, with the limbs drawn up, and the hips brought 
to the edge of the bed, opposite to a window with a good light. A Sims 
speculum being introduced into the vagina and the perineum drawn well 
back towards the sacrum, the canal will be so expanded by the air that the 
entire interior will be exposed to the eye, when the opening will probably be 
found, with perhaps a red, spongy mass, the mucous membrane of the bladder, 
protruding through it, and the urine escaping into the vagina. If any doubt 
exists, it can be removed by introducing a catheter through the urethra into 
the bladder and making it to appear in the vagina through the fistula; or 
a probe may be passed in the opposite direction from the vagina into the 
bladder. After an operation a fistula may be so nearly closed that only a 
very minute aperture remains, so small as to defy detection by a simple 
ocular inspection of the septum. In such a case the opening, however small, 
will readily be discovered by injecting the bladder with milk, the cavity of 
the vagina being exposed by the speculum during the operation. As the 
walls of the organ become distended, the milk will be seen to pass through 
the perforation and enter the vagina. 
Treatment.-The treatment of vesico-vaginal fistula embraces the prepara- 
tion, the operation, and the after-management. 
Preparation.-The surgeon is rarely called to a case of this fistula until 
after the lapse of several weeks, and patients often suffer very much from 
neglect during the interval between the time of the accident and the opera- 
tion, in consequence of the stillicidium of urine exciting inflammation, exco- 
riation, and even ulceration of the hips, the thighs, and the external organs 
of generation. It is important, before any operation is attempted, that the 
health of the woman, if impaired, should be well established, for which 
purpose it will often be necessary to administer tonics, as tincture of ses- 
quichloride of iron, at the same time attending to the state of the bowels 
and to securing fresh air and good food. The irritated and inflamed vagina 
should be washed twice a day with warm water containing a solution of 
permanganate of potash. The saline deposits can be readily removed by 
a very dilute wash of muriatic acid, while the excoriations are most expe- 744 
SURGICAL DISEASES OF WOMEN. 
ditiously healed by applying oxide of zinc ointment freely over the affected 
parts. Occasionally the fistula will require special attention preparatory to 
the formal operation. If the edges are very thin and pale, a condition un- 
favorable to union, they can be rendered thicker and more vascular by making 
slight incisions every three or four days along the margins, parallel with the 
long diameter of the opening, and rubbing into each a point of nitrate of 
silver. In a few instances, when great attention has been given to personal 
cleanliness of the parts, the fistula has healed spontaneously. No operation 
requires for its success greater attention to the general and local condi- 
tion of the patient than that for the cure of vesico-vaginal fistula. It is 
rarely proper to attempt the closure of the opening earlier than from six to 
eight weeks after its occurrence. The time for the operation, when all other 
things are favorable, is three or four days after the catamenia have ceased. 
If done late in the month, it is likely to induce the discharge prematurely. 
The day immediately preceding that appointed for the operation the patient 
should have the bowels well opened by a gentle cathartic, followed after its 
action by a grain of opium or its equivalent in laudanum. 
Operation.-Though a great number and variety of instruments have been 
devised by different operators for the closure of this fistula, I find the follow- 
ing answer every purpose: a stool or box covered with a blanket or com- 
fortable, over which the patient is to be laid, on her breast; a Sims spec- 
ulum (Fig. 1442), to expose the fistula; a pair of long, rat-toothed forceps, 
with a hook and a perforated adjuster at one end of the handle (Fig. 1443); 
two long knives to pare the edges of the opening (Fig. 1444); a needle- 
Fig. 1442. 
Fig. 1443. 
Author's forceps. 
Fig. 1444. 
Knives for vesico-vaginal fistula. 
Fig. 1445. 
Sims speculum. 
Needle-holder. 
holder (Fig. 1445) ; a self-retaining catheter (Fig. 1446) ; a few needles (Fig. 
1447), with countersunk eyes, in which to bury the silver wire, and which 
Fig. 1446. 
Fig. 1447. 
Self-retaining catheter. 
Needles. 
should be carefully tempered, so that they will admit of being somewhat bent 
before they will break; a pair of long scissors, slightly curved on the flat 
(Fig. 1448); a few sponge-mops; a shot-perforator (Fig. 1449); perforated 
shot; and silver wire. VESI CO- VAGINAL FISTULA. 
745 
Assistants.-Four assistants are necessary for the convenient execution of 
the operation,-one to administei- the anaesthetic, two to support the lower 
extremities (one of whom at the same 
time is to take charge of the speculum), 
and one to attend to sponging and to 
handing the instruments. 
Bed.-The bed should be a firm mat- 
tress, protected by a piece of rubber- or 
oil-cloth, then a sheet, and next a folded 
sheet, on which the patient is to lie. 
Having removed the clothing, except a 
chemise and night-gown, the woman is 
placed under the influence of ether, and 
then laid, with the breast and abdomen 
downward, over the stool or box. Her 
head and shoulders must be supported 
on an inclined plane of pillows. Or, if 
the surgeon prefers, she may be placed 
on the side, with the limbs drawn up and 
the hips elevated. The former posture 
is the one which I prefer. The surgeon 
now, taking his seat behind the patient, 
introduces the lever-speculum into the- 
vagina, and commits it to the care of 
one of the assistants supporting the 
limbs. (Fig. 1450.) Picking up the 
tissue at the circumference of the fistula 
with the forceps, the surgeon freshens 
the edges, taking care that the vivified 
surface shall be sufficiently wide, that is, from three-eighths to half an inch, 
and stopping just where the mucous membrane of the bladder and the border 
Fig. 1448. 
Fig. 1449. 
Scissors. 
Shot-perforator. 
Fig. 1450. 
of the fistula join. This part of the operation is most expeditiously done by 
the knife, and may, at certain points, be aided by the use of the scissors. 
Sometimes the operator is annoyed by the repeated protrusion of the mucous 
membrane of the bladder through the opening, interfering with the process 
Position, and speculum in place. 746 
SURGICAL DISEASES OF WOMEN. 
of paring. This can be prevented by pressing a piece of sponge into the 
fistula until the cutting is completed. Unusual care is to be observed that 
at the angles of the fistula no point escapes the knife. The bleeding is 
seldom profuse, and generally soon ceases on the application of cold water 
thrown upon the raw surface in a continuous stream. If this is not suf- 
ficient, hot water may be applied in the same manner, or by a piece of lint 
or linen dipped in the boiling fluid and, the redundant liquid having been 
pressed out, applied directly to the bleeding part. If this does not succeed, 
the best course is to proceed at once to close the wound by the insertion of 
the stitches, which soon control the bleeding. 
Introduction of sutures.-This, to one not practically familiar with the oper- 
ation, is a task not unattended with difficulty. The first suture must be placed 
at the middle of the wound, after which those on either side are introduced. 
The distance between the stitches should be about three-sixteenths of an 
inch. In passing the sutures, the needle, threaded with silver wire, is placed 
within the grasp of the holder, and pushed through the lower lip of the 
wound, while the latter is being steadied by the forceps, entering the tissues 
half an inch from the denuded surface, and emerging at its upper margin. 
As soon as the point of the needle becomes distinctly visible, it should be 
seized by the needle-holder and drawn through. In the same manner the 
needle is made to traverse the upper side of the fistula; and, in order to pre- 
vent the soft parts from pushing before its point, the hook at the handle of the 
forceps should be placed against the tissues, so as to make counter-pressure. 
(Fig. 1451.) When the sides of the fistula are near together, the needle can be 
Fig. 1451. 
Passing the needle while counter-pressure is made. 
made to traverse both at the same time. In passing the needle it must not be 
allowed to include the mucous membrane of the bladder, as such inclusion is 
liable to provoke vesical tenesmus. The stitch being completed, the ends 
of the wire are passed through one of the perforated shot, temporarily- 
fastened by being twisted on themselves, and given into the care of one of 
the assistants supporting the limbs, that 
the suture may be kept out of the way 
of the operator. The sutures being all 
placed in position (Fig. 1452), the oper- 
ator proceeds to the adjustment. 
The wire first introduced is to be sepa- 
rated from the others, its ends passed 
through the hole in the adjuster on the 
handle of the forceps, and as the latter 
is forced down the suture is drawn upon 
until the sides of the fistula are brought 
into accurate apposition, observing that 
no clot intervenes, when the shot can be 
clamped by the compressor. (Fig. 1453.) 
Each suture having been treated in a 
similar manner, the ends are to be cut off close to the shot (Fig. 1454), 
when the operation will be completed. 
The woman is next placed in bed, on her back, and the self-retaining catheter 
introduced into the bladder. That the bed-clothing and person of the patient 
Fig. 1452. 
Sutures introduced. VESICO-VAGINAL FISTULA. 
747 
may be preserved dry, one end of a piece of light gum tubing should be passed 
over the extremity of the catheter, while the othei* is placed in a bottle, 
lodged in an opening 
made in the centre of 
the bed, below the hips. 
In the absence of this 
arrangement, a teacup 
or saucer can be placed 
under the end of the 
catheter to receive the 
urine. 
Subsequent Treat- 
ment.-The success of 
an operation for vesico- 
vaginal fistula will de- 
pend very much on the 
after-management. The 
catheter will require to 
be watched, in order 
that no impediment to 
the flow of the urine shall exist. There should always be two instruments 
on hand, so that on removing one the other can immediately be introduced 
into the bladder. For the first twenty-four hours it may be necessary to make 
the change three or four times, on account of the passage of small coagulse 
of blood; but after this period twice will be sufficient,-once in the morning 
and once in the evening. The position on the back is that best adapted to 
the successful drainage of the bladder, as well as to the comfort of the patient. 
The bowels are to be kept quiet for the first four days, and for this object, 
together with that of relieving any nervous restlessness incident to the re- 
straints of the bed, half a grain or a grain of opium may be administered 
morning and evening. On the evening of the fourth day a gentle laxative 
may be given, after which the anodyne is to be suspended during the rest of 
the treatment, unless specially required on account of some accidental pain. 
Sleeplessness is best provided against by bromide of potassium. Should the 
patient suffer from spasms of the bladder, causing the catheter to be expelled, 
or should there occur rectal tenesmus, a suppository of opium or an enema of 
laudanum will quiet the vesical or intestinal irritability. Flatulent disten- 
tion of the bowels is best relieved by turpentine, or by aromatic spirit of 
ammonia, with a little tincture of cardamom. 
Diet.-For the first four days the diet should consist of milk and beef-tea; 
after that more solid food, and a greater variety, may be allowed, as eggs, 
cream-toast, broth, fresh meats, coffee, and tea. 
Removal of sutures.-On the seventh or eighth day following the operation 
the stitches are to be removed, and for this purpose the position on the side, 
across the bed, and with the limbs drawn up, will answer. Generally it will 
not be necessary to administer anaesthetics, as little pain will be experienced. 
In nervous, timid patients a few inhalations may be given to obtund sensi- 
bility while the wires are clipped and drawn away. In cutting and with- 
drawing the stitches, the cavity of the vagina is to be exposed by the Sims 
speculum. Any mucus which obscures a proper view of the parts is to be 
mopped away, after which the surgeon, seizing one of the shot with the long 
forceps, holds it fixed, while the wire is cut on one side with the scissors, 
at the same time straightening the hooked end of the thread. After this pre- 
liminary measure the blades of the closed scissors are to be placed against 
the loop on the opposite side, when by drawing on the shot the wire will be 
made, during its removal, to revolve about the instrument as a fixed point. 
(Fig 1455.) This manoeuvre, so easy of execution, will not only prevent a 
possible laceration of the cicatrix, but will also cause the patient little or no 
pain. 
Fig. 1453. 
Shot-compressor. 
Fig. 1454. 
Wound closed, shot clamped, and ends of wire cut off. 748 
SURGICAL DISEASES OF WOMEN. 
The sutures being removed, the patient must be returned to her original 
position in bed, and the catheter again inserted. It will not be proper to dis- 
pense with the use of this instrument, or to allow the woman to sit up, for at 
least four or five days after the stitches have been taken away, 
as the cicatrix might open if the bladder was allowed to become 
distended with urine. Even after both bed and catheter have 
been relinquished, I insist on the patient emptying the bladder 
for a few days at shorter intervals than would be her custom in 
health. 
If, on withdrawing the sutures, it is found that a small point 
of the fistula remains unhealed, let it be immediately refreshened, 
and again closed by suture, and the treatment continued as in 
the first instance. When a large opening remains, no operation will be 
propel' at an earlier period than six or eight weeks. 
Failure will occasionally follow the operation for vesico-vaginal fistula, and 
when it does it can generally be traced to insufficient denudation or inaccurate 
apposition ; to the edges of the fistula being thin, unyielding, and defective 
in vascularity; to an abnormal softness of the tissues unfavorable to holding 
the sutures; or, finally, to some imperfection in the general health inimical 
to the work of repair. Whatever may be the explanation of the miscarriage 
of the operation, the surgeon is not to be discouraged. The disqualification 
must be corrected, and the work of closing the fistula renewed until his 
efforts are crowned with success. 
Sequels.-It may happen, when a fistula situated at the neck of the bladder 
has been successfully treated, that a certain degree of incontinence follows. 
This may be due to a loss of power in the sphincter vesicas, or may be a 
consequence of too much traction on the lower wall of the urethra, producing 
a patulous state of the meatus. Time alone can correct this defect, by the 
general elongation of the shortened tissues. Simon, in the treatment of 
vesico-vaginal fistula, does not deem the metallic suture, the catheter, or the 
recumbent position necessary. Without attempting any other criticism of 
this statement, I shall only say that the plan advocated by the learned 
professor at Heidelberg is not adapted to American women. 
Complications.-A vesico-vaginal fistula may be complicated by location, 
extent, and structure. When situated high, near the insertion of the vagina, 
and posterior to the neck of the uterus, its closure can be effected only by 
attaching the lower margin of the opening to the posterior lip of the cervix 
uteri, or by turning the cervix into the bladder and stitching the inferior 
border of the fistula to its anterior semi-circumference. When I have been 
compelled to adopt 
the latter course, no 
inconvenience fol- 
lowed the presence 
of the menstrual 
fluid, which was 
passed through the 
bladder. The oper- 
ation, in other re- 
spects, does not differ 
from that practiced 
in fistulas lower 
down in the vagina. 
In some very un- 
fortunate cases al- 
most the entire 
vesico-vaginal sep- 
tum sloughs away. 
(Fig. 1456.) In this sad state two operations have been performed with a view 
to give relief, namely, episiorrhaphy and kolpokleisis. The first consists in 
Fig. 1455. 
The shot and 
loop of wire 
after removal. 
Fig. 1456. 
Destruction of almost the entire vesico-vaginal septum. UTER0-VESICAL FISTULA. 
749 
closing up the external opening of the vagina by freshening and uniting 
together the labia majora, an operation devised by Vidal de Cassis, and 
which generally leaves a small opening immediately below the urethra, 
through which the urine trickles away. The other operation, or that of 
kolpokleisis, introduced by Professor Simon, aims at uniting the posterior 
wall of the vagina to whatever may remain of the vesico-vaginal septum. 
(Fig. 1457.) The effect of the urine on the vagina is always prejudicial to its 
Fig. 1457. 
Closing up the vagina; edges pared and sutures introduced. 
structures. The evils which follow these procedures are greater than those 
which the operation proposes to overcome. A resort to either method can 
rarely be required. A much better plan of providing for these unfortunate 
cases is that of Bozeman, by which the uterus is gradually drawn sufficiently 
far down to admit of the anterior or posterior lip of the cervix being denuded 
and united by sutures to what remains of the septum between the bladder 
and the vagina, and closing the opening. Bringing the womb down for this 
purpose cannot be done at once; it will require that the traction be applied 
daily, until the tissues stretch sufficiently for the purpose in view, and often 
success is reached only after the knife has been applied to opposing bands 
of cicatricial tissue. 
Utero-Vesical Fistula. 
In the production of a utero-vesical fistula there are two factors : first, the 
vesico-vaginal septum at the insertion of the vagina on the neck of the uterus 
has been subjected to long-continued and severe pressure against the pubes 750 
SURGICAL DISEASES OF WOMEN. 
by the foetal head, the effect of which is to produce a circumscribed slough; 
and, secondly, as has been shown by Emmett, a laceration of the cervix has 
taken place, which heals up spontaneously, with the exception of that part 
opposite the damaged part of the bladder. 
Treatment.-To obliterate a defect of the above nature, the anterior lip 
of the uterine neck should be slit up to the fistula with a pair of long scissors, 
while the parts are steadied by a tenaculum or hook. In order that the 
edges of the fistula may be vivified and advantageously shaped for approxi- 
mation, the first incision should be joined by two diverging cuts at its upper 
extremity, thus excising a portion of the uterine tissue, leaving a wound 
resembling the letter Y. The gap is to be closed by silver sutures, which 
are to be secured by the shot-clamp and allowed to remain undisturbed for 
six or seven days before being removed. 
When the fistulous opening is too high in the neck to admit of being thus 
treated, there remains no alternative but to freshen and close up the lower 
part of the canal of the cervix by sutures, thus turning the menses into the 
bladder. 
Vesico-Utero-Vaginal Fistula. 
In vesico-utero-vaginal fistula the opening into the bladder occurs near 
the insertion of the attachment of the vagina to the neck of the uterus, 
and is produced in the same manner as the utero-vesical- fistula. Occasionally 
the anterior lip of the cervix is lost by sloughing, in common with the vesico- 
vaginal septum. 
Treatment.-In closing a fistula of this kind, the one lip of the cervix 
uteri must be utilized by being freshened and attached by sutures to the 
vesico-vaginal septum, similarly denuded, which forms the lower boundary 
of the opening. If the anterior lip of the neck has been lost, the posterior 
lip can be used for the same purpose. 
Surgical Affections of the Uterus. 
Preliminary Observations.-In examining the uterus the practitioner 
resorts to both the digital and the instrumental method. By means of a 
digital exploration, or the " touch," the position of the organ, its mobility, 
alterations in the size, form, sensibility, and structure of the os and the 
cervix, and often the existence of fibroid growths or of other tumors, can be 
ascertained. 
The examination may be made either in the recumbent or in the standing 
posture. When the former is selected, it can be practiced with the woman 
either on the side or on the back. If on the side, the limbs should be drawn 
up and the hips brought close to the side of the bed. If the dorsal decubitus, 
which is the best, is preferred, the limbs should also be flexed. The hands 
of the practitioner having been well washed and the nails thoroughly cleaned, 
he takes his seat by the side of the bed, and, passing his hand beneath the 
clothing, introduces the index finger, previously well smeared with olive oil 
or cold cream, into the vagina, the other fingers with the thumb being 
strongly flexed so as to avoid contact with the genitalia, and, carrying it in 
different directions, acquires such information as may be desired. The more 
gentle and light the touch of the finger, the more satisfactory will be the 
information gained. 
By making simultaneous pressure over the abdomen immediately above 
the pubes, while the finger is in contact with the cervix uteri (Fig. 1458), a 
correct idea can be formed of the size of the womb, its position, and the 
existence of any growths in its walls. 
Valuable information can also be acquired by a digital examination made 
through the rectum. In retroversion the fundus of the uterus will be felt 
encroaching upon the bowel, and fibromata, when seated in the posterior SURGICAL AFFECTIONS OF THE UTERUS. 
751 
wall of the organ, may be readily detected, as also 
of the ovaries. There should be in 
these examinations no exposure what- 
ever of the person of the female. 
When the "touch" is employed in 
the standing posture of the patient, 
the physician kneels on one knee by 
the side of the woman and passes the 
hand beneath the clothing and in front 
of the thighs. Though it is some- 
times possible to form a more just 
appreciation of the exact situation of 
the uterus when the examination is 
made in this way, the position is one 
so mortifying and repugnant to the 
feelings of a lady of ordinary deli- 
cacy and sensibility, that, unless a 
matter of absolute necessity, it should 
never be insisted upon. 
Instrumental examination.-Not only 
is it necessary to feel, but in many 
cases to see also the interior of the 
vagina and the neck of the uterus. 
For the latter purpose the speculum is 
employed. There are three varieties 
of the instrument, which answer any purposes,-the Sims or duck-bill (see 
Fig. 1442;, the bivalve (Fig. 1459), and the cylinder speculum (Fig. 1460). 
Fig. 1458. 
Simultaneous abdominal and vaginal examination. 
Fig. 1459. 
Bivalve speculum. 
The Sims speculum is an indispensable instrument in the operation of vesico- 
vaginal fistula. The bivalve speculum has undergone various modifications. 
Fig. 1460. 
The best is that in which two movements of the blades can be made,-the 
one an oblique and the othei' a parallel separation. 
The cylinder speculum is constructed generally of glass or hard rubber. 
The latter material is much the safer. Two or three sizes should be on band. 
Cylinder speculum. 752 
SURGICAL DISEASES OF WOMEN. 
In addition to the speculum it is necessary in many cases to employ a uterine 
sound (Fig. 1461), by which displacements can be corrected, the depth of the 
Fig. 1461. 
Uterine sounds or probes. 
uterus determined (there being a scale marked on its surface), and growths 
in its cavity discovered. The instrument is made of steel, copper, or German 
silver, the two last materials being generally the best, as the curve can be 
altered at pleasure to suit different cases. 
Use of the speculum.-In using the Sims speculum the patient must be either 
on the hands and knees across the bed, or on the left side, with the limbs 
well drawn up, the body rolled over on the breast, and the left arm drawn 
back behind the body. When the examination is made with the bivalve or 
the cylindrical instrument, the most convenient position is that on the back 
across the bed, with the nates projecting over its sides and with the limbs 
flexed and separated and resting on a stool or chair or supported by an 
assistant, or the woman may possibly be able, by planting her feet on the 
edge of the bed, to dispense with any other support. A sheet is to be placed 
over the patient and the undergarments raised. The physician now passes 
the speculum, properly greased, underneath the clothing into the vagina, 
guided by the sense of touch, when the sheet should be tucked in around the 
limbs and the instrument in a way to leave no part of the genitalia exposed. 
If the light is properly directed through the speculum into the vagina, any 
erosion, congestion, or granulation of the neck, or any discharge from its 
canal which may be present, will be exposed to view. 
The sound or probe can be introduced into the uterus either on the finger 
as a guide, with the patient on her back and her limbs drawn up, or through 
the speculum, when that instrument is used. The utmost gentleness and 
tact are necessary in employing the sound. Force is not allowable; and if 
it does not pass readily, it will be due either to a defective curve of the instru- 
ment, which must be changed, or to some mechanical obstruction in the canal 
of the cervix or the cavity of the uterus. 
Sometimes it becomes necessary to fix the womb or to draw it down during 
Fig. 1462. 
Hook for the neck of the uterus. 
Fig. 1463. 
Claw-toothed forceps. 
manipulation, which can be most satisfactorily done by sinking into its neck 
a hook (Fig. 1462) or a pair of claw-toothed forceps. "(Fig. 1463.) MALPOSITIONS. 
753 
Mops for cleansing or swabbing out the neck of the uterus or the vagina are 
Fig.1464. 
Sponge-holder. 
readily made by fastening bits of soft sponge between the blades of a holder. 
(Fig. 1464.) 
Malpositions. 
The uterus may be displaced downward, forward, backward, or laterally. 
Procidentia Uteri, or displacement of the uterus downward, arises from 
the weight of the uterus being increased by engorgement of the organ, or by 
hypertrophy of its neck; from lacerations of the perineum, which permit 
also protrusions of the posterior wall of the vagina; from relaxation of the 
utero-sacral ligaments; and from tumors, abdominal or pelvic, which crowd 
the organ downward. I believe a large number of the cases of prolapsus 
arise from women getting up too soon after labor. The degree of displace- 
ment varies in different cases, from a very slight sinking of the uterus to its 
complete extrusion (Fig. 1465) through the vulva, attended necessarily by 
inversion of the vagina. 
Symptoms.-Prolapsus of the uterus is accompanied by a sense of weight 
Fig. 1465. 
Extreme degree of procidentia uteri: a, anterior wall of vagina; 6, os uteri. 
in the pelvis, with dragging sensations about the hips and pain in the lumbar 
region, especially when the patient is standing or walking. The displace- 
ment not unfrequently produces more or less vesical irritation from the trac- 
tion exerted on the bladder, and if of long duration occasions disorder of the 
digestive and nervous systems. By the "touch" the displacement is readily 
recognized. 
Treatment.-The management of a case of prolapsus uteri is often a 
matter of great difficulty. Unfortunately, the mechanical measures which 
vol. it.-48 754 
SURGICAL DISEASES OF WOMEN. 
are so generally in use, while they give a temporary support to the womb, 
tend to enlarge the capacity of the vagina, which of itself constitutes a de- 
termining cause of the displacement; and yet in a large number of cases no 
other plan is advisable. The treatment may be divided into the mechanical, 
the medical, and the operative. 
Mechanical Treatment.-This consists in plac- 
ing a prop or pillar of support between the neck 
of the uterus and the perineum. This is done 
by means of pessaries, of which there are several 
patterns, some globular, some rings (Fig. 1466), 
and others oblong, lever-, and stem-shaped. These 
pessaries are made of glass, metal, bard rubber, and 
soft rubber. The pessary in general use, and the 
least objectionable one of all, is that devised by the 
late Professor Hodge (Fig. 1467), or one of its modi- 
fications. The large extremity of this instrument 
is placed in the utero-vaginal notch behind the 
neck of the womb, with its convexity downward, 
the small extremity behind the arch of the pubes 
and below the urethra. (Fig. 1468.) 
Fig. 1466. 
Meigs's ring pessary. 
Fig. 1467. 
Two varieties of Hodge's lever pessary. 
When the floor of the perineum has been damaged, or the dilatation of 
the vagina is so great that the lever pessary is not retained, and the uterus 
descends into the vulva, the 
cup pessary. (Fig. 1469) can 
be substituted for a time with 
advantage. 
The os and neck of the 
womb, -when this instrument 
is applied, rest in the cup at 
the end of the stem, the latter 
being supported by a perineal 
band, which is attached to an- 
other band, surrounding the 
body above the hips. 
When the uterus is lifted 
into place its weight rapidly 
diminishes, whether it has 
been the result of passive 
engorgement or of cervical 
hypertrophy. 
Medical Treatment.-At 
the same time that mechanical supports are being employed, much good can 
be done by astringent vaginal injections. Among these none appear to fulfill 
the indications of securing cleanliness and causing a tonic contraction of the 
Fig. 1468. 
Adjusting the lever pessary. MALPOSITIONS. 
755 
canal better than a strong decoction of oak bark or of alum, which should be 
used daily. If the general system of the patient is weak, the administration 
of tonics, as quinine, nux 
vomica, and iron, will prove 
beneficial. 
Operative Measures. - 
When the procidentia fol- 
lows a laceration of the per- 
ineum, little relief can be 
looked for until the latter 
has been restored by an 
operation. 
With a view of sustaining 
the uterus by getting rid of 
redundant vaginal tissues, 
several operations have been 
devised. For the suggestion of these the profession is indebted to Marshall 
Hall, though he himself, I believe, never carried his plans into effect. 
Dr. Sims, in 1858, first gave to this method a practical trial by making a 
V-shaped denudation on the anterior wall of the vagina, the apex of the V 
being situated at the neck of the bladder, and the two freshened strips, which 
diverged as they ascended, terminating one on either side of the vagina a 
little below the neck of the uterus. Interrupted silver sutures were then 
passed across, and these surfaces brought together and secured in the median 
line. This operation I have done a number of times, but with only partial 
success. It is, however, one which is somewhat difficult to perform, and has 
been replaced by another, which is easier of execution and more efficient in 
its results. In this method, while the uterus is pushed by a sponge probang 
up into the posterior cul-de-sac, the mucous membrane of the vagina is de- 
nuded at three distinct points,-one, the largest, transversely in front of the 
neck of the uterus, and one on each side, just at the extremities of the first, 
and joining at the neck of the bladder. These surfaces are brought into 
contact with one another just in front of the cervix by a silver suture, thus 
fixing the uterus in the fold or 
collar made from the vagina. (Fig. 
1470.) The lateral branches of 
denudation are then closed by 
silver sutures, four or five in num- 
ber to the inch.. The stitches are to 
be removed from the eighth to the 
tenth day. During the treatment 
the bladder is to be kept empty 
by periodical catheterization, or by 
the continuous retention of Sims's 
catheter. 
Emmett, instead of making one 
line of denudation across the vagina 
below the cervix, makes three vivi- 
fied surfaces, one on each side of 
the neck of the womb, and the third between the lateral ones, each separated 
from the other by the mucous membrane of the vagina. The three raw sur- 
faces are then brought together by sutures. 
Another plan is sometimes adopted, of freshening the greater labia and 
uniting them well forward by sutures, so as to offer an obstacle at the vulva 
to the escape of the prolapsed uterus. This will frequently succeed when 
other measures fail; but it should be a last resort. 
Fig. 1469. 
Cup pessary. 
Fig. 1470. 
Form of the denuded surface, with the sutures introduced, 
in the operation for prolapsus of the uterus. 
Retroversion.-In this displacement the fundus of the uterus falls back- 
ward and downward in various degrees, from the slightest posterior inclina- 756 
SURGICAL DISEASES OF WOMEN. 
tion to that in which the organ reaches the hollow of the sacrum. The 
neck is turned towards the pubes. (Fig- 1471.) It occurs both in the un- 
impregnated and in the pregnant uterus, and is sometimes bound down in 
its unnatural position by adhesions. The 
causes producing retroversion are vas- 
cular engorgement, the existence of a 
fibroid, cither in the posterior or in the 
anterior wall of the organ, and over- 
distention of the bladder. 
The signs of the displacement are 
fullness and weight in the pelvis, with 
dragging lumbar and sacral pains, accom- 
panied by a frequent desire to micturate, 
especially when prolapsus is also present, 
the bladder being then drawn or dragged 
upon. There is experienced frequently 
some little difficulty in defecation, owing 
to the pressure of the body of the uterus 
upon the rectum. A digital examination 
made through the latter intestine will 
enable the physician to detect the fundus 
of the womb encroaching upon the bowel; 
by the vaginal touch he may recognize 
the os directed towards the pubes. 
Retroversion may provoke dysmenorrbcea, inflammation of the bladder, 
or congestion of the rectum, and may also cause sterility. Even the loss of 
locomotion may follow this displacement, from pressure on the sacral plexus 
of nerves. 
Treatment.-Unless tied down by adhesions, the uterus should be imme- 
diately replaced, as the longer it is allowed to remain retroverted the greater 
will be the difficulty of keeping it in its normal position. When the retro- 
version occurs in the impregnated organ, the necessity for its reduction is 
urgent, as it may, if neglected, provoke miscarriage, or the womb may become 
so impacted under the promontory of the sacrum by the development of the 
foetus as to render all efforts for the purpose unavailing. Early reductions 
are also of prime importance when a fibroid growth located in the walls of 
the organ has occasioned the displacement, as morbid processes are intensified 
by all causes favoring uterine congestion, of which retroversion is one. In re- 
placing a retroverted uterus the patient should be put in one of two positions, 
-either on her back with the limbs drawn up ami the pelvis elevated, or on 
her knees and breast with the hips raised. Upon raising the hips the intes- 
tines gravitate away from the pelvis, and thus leave measurably vacant the 
anterior utero-vesical space. A sound or a repositor (Fig. 1472) now being 
Fig. 1471. 
Slight retroversion of the uterus. 
Fig. 1472. 
Sims's elevator, or repositor. 
passed into the uterus (Fig. 1473) and used as a lever, the organ can, in recent 
cases, he readily raised into place (Fig. 1474), after whicl? a level* pessary 
must be immediately adjusted, in order to prevent a recurrence of the dis- 
placement. The patient will do well to remain in the recumbent position for MALPOSITIONS. 
757 
twenty-four hours after the adjustment, as the tendency of the organ to topple 
over again is greatly diminished by rest. To prevent a recurrence of the 
Fig. 1473. 
Repositor introduced into the uterus preparatory to replacing it. 
displacement, a Hodge pessary as modified by Dr. Albert Smith should be 
introduced before the patient is allowed to rise from the bed. 
Fig. 1474. 
Uterus raised into position by repositor. 
When the retroversion has existed for some length of time, and when 
adhesions have formed so as to tie the uterus down, the restoration can only 
be effected gradually, by elongating the inflammatory bands by pessaries of 
different lengths, using first a short one and by degrees longer ones as the 
adhesions yield, until finally the difficulties are surmounted. Forcible at- 
tempts to burst the checks arising from inflammatory attachments are not 
without danger, as they may give rise to a pelvic cellulitis vastly more to be 
deprecated than the condition which they are designed to rectify. When- 
ever, therefore, severe pain is complained of, it will be better to discontinue 
for the time all efforts to correct the retroversion, or else to adopt gentler 
measures. 
When the knee-and-breast position is adopted,-one which I have fre- 
quently called to my aid both in cases of obstinate retroversion arising from 
ordinary causes and in those caused by fibroids,-the woman is placed on 
her knees, the chest resting on the folded arms, and the hips being well 758 
SURGICAL DISEASES OF WOMEN. 
raised. In this posture the viscera gravitate towards the diaphragm, when 
a finger introduced either into the vagina or into the rectum and pressed 
against the fundus of the uterus will usually cause it to resume the proper 
position. Should this not follow, the same posture is admirably adapted for 
the application of the repositor. 
Pi'olessor Campbell, of Georgia,* as early as 1875 called the attention of 
the profession to the value of postui'e, associated with pneumatic pressure, 
in correcting uterine displacements. Several very important directions are 
given in connection 
with this plan, particu- 
larly with reference to 
the character of the 
curvature of the spine, 
which should be deeply 
concave instead of being 
convex. (Fig- 1475.) 
In this position, if the 
vagina is opened, the 
inrushing air expand- 
ing the canal will, with 
the gravitation of the 
viscera, induce a spon- 
taneous correction of 
the displacement. The 
woman, by adopting this plan, has the remedy in a great measure in her own 
hands. 
The colpeurynter passed well up into the vagina and distended either with 
air or with water is occasionally resorted to for overcoming a retroversion: 
as the bag enlarges, the womb is pushed up out of the hollow of the sacrum. 
A difficulty sometimes encountered in reducing retroversions by the finger 
alone, is to make the fundus of the uterus clear the promontory of the 
sacrum. This may require digital pressure made through the rectum, or it 
can be overcome by adopting the plan practiced by Emmett, which is to sink 
a hook into the neck of the uterus, drawing it down towards the outlet of 
the vagina, while at the same time a finger is passed up behind the body of 
the organ and the lattei' pressed forward towards the pubes. When the 
fundus has risen sufficiently to pass the promontory of the sacrum, the cer- 
vix is to be pushed backward and downward,-a movement favorable to 
one upward and forward of the body of the womb. When there is reason to 
believe that the retroverted uterus is pregnant, of course it will be improper 
to introduce a sound into its cavity. 
Fig. 1475. 
Genu-pectoral position. 
Anteversion.-In anteversion the fundus of the womb is carried forward 
towards the pubes, and the os backward towards the hollow of the sacrum. 
(Fig. 1476.) The displacement as compared with retroversion is quite in- 
frequent. 
The causes which determine anteversion are hypertrophy of the body of the 
womb, pelvic tumors, false bands (the product of a pre-existing peritonitis), 
tight lacing, cystocele, etc. 
Very little inconvenience attends the displacement, unless it is accom- 
panied by prolapsus, when the drag on the bladder is prone to provoke a 
cystitis. Anteversion is sometimes attended with a certain degree of pelvic 
discomfort analogous to that produced by retroversion. 
Very positive information is revealed by the "touch" when the neck of 
the womb is felt far back towards the sacrum. 
Treatment.-Unless the symptoms are urgent, little interference is re- 
quired in cases of anteversion. Indeed, the displacement is much less amena- 
* Resum6 of a Report on Position and Pneumatic Pressure and Mechanical Appliances in Uterine 
Displacements, 1876. UTERINE FLEXIONS. 
759 
ble to correction by mechanical means than is retroversion. If the woman has 
a pendulous belly, or is at all given to corpulency, the use of an abdominal 
supporter will constitute a valuable auxiliary in the treatment, by sustaining, 
to some extent, the weight of the intestines. I have seen many patients 
derive quite as great comfort from a properly-adjusted abdominal supporter 
as from any intra-vaginal supporter. 
A lever pessary similar to that employed in cases of retroversion, with its 
upper end behind the cervix uteri, will often give relief simply by raising 
the womb, notwithstanding that the tendency of the support is to increase 
the anteversion. All tight lacing should be abandoned. Thomas's antever- 
sion pessary (Fig. 1477) will frequently be found to afford the greatest relief. 
Fig. 1476. 
Fig. 1477. 
Anteversion of the uterus. 
Thomas's anteversion pessary. 
Women should be taught to remove and replace their pessaries. The pos- 
session of this kind of tact will administer greatly to their comfort and safety. 
When the vesical irritation becomes so great as constantly to harass and 
render miserable the patient, two courses are open to the surgeon,-elytror- 
rhaphy or cystotomy. The first consists in denuding transversely two strips 
on the anterior wall of the vagina, the upper one in close proximity to the 
neck of the uterus, and the other about one inch lower down, and uniting 
the raw surfaces by silver sutures. 
It is contemplated in this operation to drag the neck of the uterus for- 
ward by diminishing the length of the vagina, and in this manner carry the 
body of the womb backward. The procedure is not a very successful one. 
Cystotomy, which has been advised, aims at placing the bladdei' at rest, 
with a view of controlling the cystitis caused by the drag on the bladder. 
The operation is performed by making an opening into the bladder behind 
its neck, through the vagina, and allowing the water to drain away through 
the latter canal. It has been frequently done, but only with partial success. 
Even after such a fistula is established, it will be necessary to use a pessary 
to raise the womb; otherwise the vesical irritation will continue unabated. 
Uterine Flexions. 
Flexions of the body and of the neck of the uterus are met with in both 
married and unmarried women, in the sterile and in the fruitful. That of 
the neck is very much the more common. In unmarried women the flexion 
is developed about the period of puberty, the bend occurring at the point 
where the vagina is inserted on the neck of the womb. Uterine flexions are 
as varied as the versions. The two most commonly encountered are ante- 760 
SURGICAL DISEASES OF WOMEN. 
flexion (Fig- 1478) and retroflexion. (Fig. 1479.) In the former the cervix is 
Fig. 1478. 
Fig. 1479. 
Anteflexion of the uterus. 
Retroflexion of the uterus. 
bent forward at a more or less acute angle with the body of the womb. In 
the latter the flexion is sometimes the result of a retroversion. 
The cause of flexions at this period of life is believed to be an asymmetrical 
development of the cervix and the body of the uterus, probably from changes 
induced by conformity to modern modes of life. 
When the flexion makes its appearance later in life and in married women, 
it may be referred to inflammatory changes affecting the submucous con- 
nective tissue of the cervix, and produced by difficult labor, oi' by abortions, 
criminal or otherwise. 
Some writers, and with great plausibility, attribute these flexions to the 
unequal tonicity or contractility of the superficial and deep portions of the 
longitudinal muscular fibres of the organ. 
When occurring in the unmarried, they are often due to the effects of cold, 
especially cold taken during menstruation. Lateral flexions have in most 
cases an inflammatory origin. 
The evils which follow uterine flexions are dysmenorrhcea and often 
sterility. 
The diagnosis of uterine flexions is readily established by a digital exami- 
nation, by which the deviation of the womb from the proper position, and 
the bend at the junction of the cervix and the body of the uterus, can be 
detected. 
Treatment.-The existence alone of a slight cervical flexion is no reason 
for instituting treatment. It does not follow that all women with flexions 
are doomed either to painful menstruation or to sterility. Many, indeed, 
escape both, and young women who realize considerable pain at the begin- 
ning of a " period," or even for two or three days during its progress, will, 
after marriage, menstruate without suffering. It is only, therefore, when 
dysmenorrhcea is severe and persistent, or when the sterility seems to be 
pronounced, that surgical interference is to be advised. When the flexion is 
posterior and only the outcome of a retroversion, it can in a good measure 
be corrected by raising the womb from the hollow of the sacrum and sup- 
porting it on a pessary. 
In acute flexion, and also in the other varieties, sponge tents and dilating 
instruments have been introduced through the canal of the cervix into the 
cavity of the uterus, with a view of removing the deviation by straightening 
the neck, and often with considerable correcting influence. 
Something will be gained by the use of an anteversion pessary like UTERINE FLEXIONS. 
761 
Thomas's, aided by an abdominal supporter, at the same time preventing 
fecal accumulation in the lower part of the large intestine, and educating 
the bladder to retain for some time the urine, so as to secure by the disten- 
tion of its walls some pressure against the anterior wall of the uterus. The 
stem pessary was at one time in popular use for the purpose of correcting 
these flexions; but the evils which have so often followed its employment have 
most properly caused its condemnation. 
Professor Campbell uses with success a form of the pessary which removes 
some of the objections that have been urged against the old instrument, and 
which he calls the soft rubber spring stem pessary. It consists of three 
parts,-a spring of any required strength, a piece of india-rubber tubing, 
which is to be slipped over the spring, and an appliance for introducing 
and adjusting the instrument. (Fig. 1480.) Before inserting the pessary its 
Fig. 1480. 
Campbell's soft rubber spring stem pessary. 
author prepares the canal of the cervix uteri for its passage by introducing 
for a short time a sponge tent curved sufficiently to admit of its entering 
the womb without inflicting any violence upon its lining membrane. The 
stimulus imparted to the muscular fibres of the uterus, the relaxed condi- 
tion of which, according to the theory of Eiklund and Martin, constitutes 
the cause of the flexion, is influential in exciting those contractions which 
are necessary to the permanent cure of the distortion. 
Dr. Elwood Wilson relies very much for correcting flexions on introducing 
his dilator into the uterus and straightening the angle by forcibly separating 
the blades of the instrument. The longitudinal muscular fibres on the an- 
terior face of the flexion are by this process overstretched and paralyzed, 
thus giving the deep fibres an opportunity to recover their power and prevent 
a recurrence of the curvature of the cervix. 
The operation which has been devised for removing the evils of an invin- 
cible flexion is the division of the cervix uteri, including the internal os, so 
as to convert a curved into a straight canal. Some prefer the bilateral section 
introduced by Sir James Simpson, and advocated, I believe, also by Sims. 
Others, as Emmett, confine the incision to the posterior lip. The bilateral 
method is more likely to be followed by profuse bleeding; at least such has 
been my experience. There is also danger of transcending the limits of the 
vagina and exposing the cellular tissue of the pelvis; and, even when no 
such accidents follow, it possesses no advantage over the section of the pos- 
terior part of the cervix. 
In dividing the posterior part of the neck, the patient is to be placed on 
the left side, with the hips projecting over the side of the bed, the uterus 
being exposed by introducing a Sims speculum into the vagina and drawing 
the perineum back. The operator sinks a long tenaculum into the anterior 
lip of the cervix, and drags the uterus well forward with one hand, while 
with the other he introduces one blade (the blunt-pointed one) of a pair of 
curved scissors (Fig. 1481) into the canal of the cervix, and the other along 
its posterior surface in the median line, and up to the insertion of the vagina; 
then, by closing the blades, the intermediate tissue of the neck will be divided. 
As there generally remains a small portion of uterine structure at the in- 762 
SURGICAL DISEASES OF WOMEN. 
ternal os which escapes the scissors, it should be incised by the uterotome. 
(Fig. 1482.) 
A sound must now be passed into the womb, to ascertain if the canal is 
freely laid open: if this is the case, a roll of absorbent cotton soaked in 
Fig. 1481. 
Scissors for dividing the neck of the womb. 
glycerin is to be introduced into the canal and between the cut surfaces of 
the neck, and allowed to remain until loosened by the discharges, when it 
Fig. 1482. 
should be replaced by another pledget of the same kind. If the bleeding 
proves to be profuse, the vagina must be tamponed with strips of patent 
lint previously treated with a dilute solution of persulphate of iron, or with 
absorbent cotton. A suppository containing two grains of opium may now be 
administered, and the patient placed in bed. The tampon should be removed 
in forty-eight hours, unless much uneasiness is experienced: in this event 
a few strips nearest the outlet of the vagina may be extracted at an earlier 
period. In two weeks the woman may be allowed to sit up; but a quiet 
life should be enjoined for at least an additional fortnight. The operation 
should not be advised unless the evils resulting from the flexion are con- 
siderable, and until other less dangerous measures have failed. 
Uterotome. 
Lateral Flexions.-The principle which governs the treatment of anterior 
and posterior flexions should be applied to the correction of those which 
are lateral. 
Laceration of the Cervix. 
This accident, first described by Dr. Emmett, of New York, in 1869, is 
exceedingly common, occurring, according to the above-named authority, in 
32.80 per cent, of all women coming under his observation for uterine disease 
and who have had children. 
Laceration is liable to follow tedious or protracted labor, and happens par- 
ticularly in cases requiring the use of the forceps. It may affect one or both 
lips of the cervix, the anterior being the more common. The evils which 
accompany and follow unhealed lacerations are cellulitis, neuralgia, vesico- 
vaginal fistula, erosion or ulceration and hypertrophy and atrophy of the 
cervix, procidentia, endometritis, and derangement of the menstrual function. 
The general health, in bad cases of laceration, becomes seriously involved. 
The patient is pale, nervous, dyspeptic, and harassed with dragging lumbar 
and pelvic pains. 
To detect a laceration it will be proper to make both a digital and an INVERSION OF THE UTERUS. 
763 
ocular examination. When the finger is passed over the cervix anteriorly 
and posteriorly, it will be found to be greatly hypertrophied, sometimes 
exceeding in size the body of the uterus. The os will be found to be quite 
patulous. It is also possible, as the lips of the laceration are everted, by a 
delicate use of the touch to discover a notch or depression marking the line 
of the tear. 
When the parts are exposed by the speculum, and the two lips of the cervix 
are approximated by the tenaculum, the everted parts will turn inward 
towards the canal. 
Treatment.-Lacerations of the cervix, unless accompanied by much local 
distress or structural alteration, do not demand surgical interference. The 
thickening and unhealthy granulations of the lips of the fissure will be 
greatly improved by daily vaginal injections of warm water, and by painting 
the parts semi-weekly with Lugol's solution of iodine, or with tannin and 
glycerin. Should the follicles of the cervix undergo cystic degeneration, the 
cysts ought to be evacuated by punctures before the iodine is applied. When 
the case is deemed sufficiently grave for an operation, the first aim should 
be to secure the subsidence of all tenderness on pressure against the sur- 
rounding parts. To operate before this has disappeared is to subject the 
woman to the danger of an acute cellulitis. 
In executing the operation, the patient can be placed either on the left side 
or on the breast, the parts being exposed by the Sims speculum. While the 
lips are drawn forward and steadied by a tenaculum, the operator, either 
with a sharp bistoury or with scissors, pares away the edges of the cleft, 
forming as broad a denuded surface as possible. Care is to be taken also 
that the parts shall be scarified at the upper angle of the fissure, at which 
point, however (if at the juncture of the body and neck), the freshening 
should not be carried to any depth, for fear of wounding the cervical artery. 
If the bleeding is profuse, which, in the spongy condition of the neck, is 
not unlikely, hot water should be thrown upon the parts in a stream from 
a syringe. If this fails to arrest the flow, it may be necessary to pass a wire 
noose around the base of the neck, close up to the insertion of the vagina, 
and twist it until the vessels are constricted. The same end can be accom- 
plished by the single canula and wire. The denudation having been com- 
pleted, the opposed surfaces are to be accurately approximated by a sufficient 
number of silver sutures, secured either by the shot-clamp or by twisting. 
The ends of the sutures are next to be cut off* 
close and the patient placed in bed, where she 
should remain for at least two weeks after the 
removal of the stitches. (Fig. 1483.) The urine 
may be drawn by the catheter, or it may be passed 
into the bed-pan, as it is not likely to come in 
contact with the wound of the cervix. The 
vagina during the treatment should be washed 
out with warm water daily, as soon as any secre- 
tions are discovered in the canal. The diet, at 
first consisting of milk and animal broths, may, 
after the first three days, be increased to bread, 
eggs, and a moderate amount of meat. From the 
seventh to the ninth day the stitches are to be 
removed, the uppermost one first. If union has not taken place at this 
point, the others must be allowed to remain longer, so that the gap at the 
upper angle may have time to granulate and heal. 
Fig. 1483. 
Laceration freshened and sutures 
introduced. 
Inversion of the Uterus. 
The term inversion of the uterus is used to express the turning of the womb 
inside out, the internal becoming the external, and the external the internal 
surface. The inversion may be either partial or complete. The nature of the 764 
SURGICAL DISEASES OF WOMEN. 
accident was understood as early as the time of Ambrose Pare. In partial or 
incomplete inversion the fundus of the organ has not passed the limits of the os, 
while in the complete variety it has not only escaped through the os, but also 
protrudes into the vagina, or is even placed exterior to the vulva, between 
the thighs. The accident is quite uncommon. In 140,000 labors occurring 
in two lying-in hospitals, the Dublin and the London Maternity, not a single 
case occurred. The predisposing causes are twofold, namely, distention and 
relaxation of the uterine walls. The exciting or determining causes .are 
traction on an adherent placenta, the weight of a polypus, or even forcible 
extraction of the child. 
Symptoms.-The physical sign of inversion, that which alone is to be relied 
on, is the presence of a globular or pyriform spongy mass, filling up the 
vagina or lying exterior to the vulva, according as the case is one of incom- 
plete or of complete inversion. The hemorrhage is frequently very copious. 
Inversion may be confounded with polypoid or fibrous tumors. The mis- 
take can be avoided by attention to the following diagnostic signs. In a 
polypus which has passed into the vagina the tumoi' will be pedunculated; 
a probe can be passed between the pedicle and the canal of the cervix into 
the cavity of the uterus. The uterus can also be felt through the walls of 
the rectum. These peculiarities are not found in inversion. 
In fibrous tumors the uterus is pervious to the sound. The outline of the 
womb can also be traced through the rectum, and even through the abdominal 
walls, and there has been a history of gradual enlargement and probably 
occasional hemorrhages, entirely independent of pregnancy. Several times 
the inverted uterus has been amputated, under the supposition that the tumor 
was a polypus. The danger of inversion is death from hemorrhage or from 
slow exhaustion in consequence of a serous hemorrhage from the lining 
membrane of the organ. In some instances the inversion has continued for 
years. 
Treatment.-It is important that the accident be recognized early, other- 
wise the difficulties of reduction are enormously increased; but even chronic 
cases are sometimes amenable to taxis. If the placenta remains adherent, it 
must be detached, and the bleeding, if copious, checked by hot water. The 
methods of employing taxis are quite numerous, and bear the names of their 
authors. Thus, we have those of Tyler, Smith, Valentine, Noeggerath, 
Barnes, Courty, and others. In recent cases of inversion the practitioner 
should, after washing and oiling his hands, notice whether the os is relaxed 
or contracted. If the former, the mass, seized between the two hands, should 
be pushed directly upward, by which the pedicle will be first reinverted, fol- 
lowed by the body and fundus. If, on the other hand, the os is highly con- 
tracted, it will be best to indent the centre of the fundus by applying against 
it the tips of the fingers grouped together in the form of a cone, and force 
it upward until it enters the ring of the os, to be followed by the body and 
the neck. 
In chronic cases of inversion success has followed the taxis even as long 
as twelve years after the accident, as in a case of Noeggerath's. When an 
attempt is to be made to restore an old case, the bladder and rectum must 
be emptied, and the patient thoroughly etherized and placed on her back, 
with the limbs drawn up. 
In order to fix the uterus and prevent its recession, counter-pressure must 
be made above the pubes with one hand, or by introducing two fingers into 
the rectum, after Courty's plan, the uterus having been dragged down with 
a vulsellum, while, with the hand carried into the vagina, compression and 
upward pressure are applied to it. 
Noeggerath succeeded in one case by indenting the body of the uterus be- 
tween the thumb and finger opposite to each horn, and afterwards thrusting 
the horn into the canal resulting from the inversion, which was followed by 
the remaining portion of the organ. 
A case of six years' standing, admitted into a hospital at Cincinnati, was DYSMENORRHCEA. 
765 
reduced by Dr. Tate in the following manner. One finger of the operator 
was passed into the rectum and applied against the surface of the os, while 
the finger of an assistant (Dr. Dandridge, at whose suggestion the modifica- 
tion was adopted) was passed through the urethra into the bladder and ap- 
plied against the hard ring of the os at a point opposite to where the press- 
ure was applied through the rectum. The neck of the uterus being thus 
fixed, force wras exerted against the fundus with the thumbs, and a noticeable 
depression soon began to appear, and, further pressure being made by a 
candle surrounded by a rag, the reduction was finally accomplished. 
Barnes succeeded in reducing an inversion by drawing down the womb 
and slitting the cervix at two or three points, so as to relieve the constriction, 
and then pushing up the fundus. The danger in this plan is that these slits 
may become lacerations during the efforts at reposition and extend into the 
pelvis. 
Six' James Simpson proposed, in refractory cases of inversion, to open the 
abdomen and expose the seat of constriction at the os uteri in this way. 
Dr. Thomas, of New York, has twice carried this suggestion into effect, 
one of the patients dying and the other recovering. The ring of the cervix 
was stretched by a dilator introduced from above. The dangers of this pro- 
cedure, however, are much too great to allow of its practice, except as a 
forlorn hope, when the operation should be done antiseptically. 
Emmett has succeeded in restoring cases of inversion after other measures 
had failed by passing the hand into the vagina and receiving the fundus in 
its palm, while the finger and thumb were thrust between the mass and the 
cervix, thus dilating the latter, counter-pressure at the same time being made 
with the other hand above the pubes. 
When the reduction is partial,-that is, when the fundus has been restored 
within the canal of the cervix,-the same author advises closing the os over 
the mass by means of silver sutures. If retained in this manner, there is a 
reasonable prospect of complete restoration occurring spontaneously. If the 
practitioner is foiled in his attempts at reposition by the plans described, he 
should resort to gentle but continuous pressure applied by means of a cup 
for the reception of the fundus, with a stem attached, to which an elastic 
strap is fastened, the ends of the latter being secured to a band carried round 
the body after the manner of fixing the ordinary stem pessary. The pressure 
must be gradually increased as the patient is able to endure it, until re- 
duction takes place. 
Amputation.-Amputation of the uterus for the cure of inversion is an 
extreme measure, and not to be contemplated until all other methods have 
failed, and until the life of the patient is placed in great jeopardy by the evils 
resulting from the displacement. Dr. Thomas has collected 58 cases of am- 
putation for inverted uteri, of which 18 terminated fatally. 
The operation is best effected by the galvanic cautery or by the ecraseur: 
the former is least liable to be followed by hemorrhage. 
The uterus in amputation should be dragged down as far exterior to the 
vulva as possible before applying the wire of the cautery or adjusting the 
chain of the ecraseur. 
Dysmenorrhoea. 
Operative measures not unfrequently become necessary for the cure of 
dysmenorrbcea. The obstructive form of the disease is caused by distortions 
of the neck of the uterus, such as occur in flexions and versions; also by in- 
flammatory stricture of the canal of the cervix, or by the presence of a poly- 
poid growth. When the difficulty is due to flexion or version, it must be 
overcome by the plans already described under those heads. When it arises 
from stricture of the canal of the neck, the narrowing must be corrected 
either by diZatafo'on or by incision. 
Dilatation.-In this operation the patient, previously etherized, is placed 
on the back across the bed, with the limbs drawn up. The operator then in- 766 
SURGICAL DISEASES OF WOMEN. 
troduces a finger into the vagina and touches the os. Along this finger as 
a guide is passed a dilator (Fig. 1484), the point of which is directed into the 
uterus, when the blades are to be forcibly separated, thus stretching the 
Fig. 1484. 
Dilators for the eervix uteri. 
cervix. A suppository of opium, and rest in bed for twenty-four or thirty- 
six hours, constitute the after-treatment. 
Another plan is to expose the os by expanding the vagina with a bivalve 
or a Sims speculum, then drawing the neck forward with a hook and steady- 
ing it while the dilator is introduced and the cervix dilated. 
Incision is designed to enlarge the canal of the neck without dilatation, 
and is accomplished either by the hysterotome of Simpson, who devised the 
operation, or by scissors, as practiced by Sims. 
In performing the latter operation, which may be considered the more satis- 
factory, the uterus is exposed by a Sims speculum, the woman being placed 
on her left side. A tenaculum is next sunk into the neck of the womb, with 
a view of fixing the organ, when the blunt-pointed blade of the uterine 
scissors is passed into the canal of the cervix sufficiently far to bring the 
point of the other blade to the insertion of the vagina, and the intermediate 
tissue is divided. A similar cut is made on the opposite side, thus making a 
bilateral section of the cervix. After sponging away the blood, a pledget of 
absorbent cotton soaked in glycerin is packed into the wound, and a vaginal 
tampon applied, which should be left in for twenty-four hours. After the 
lapse of three days the cotton must be extracted from the wound and re- 
placed by another roll, prepared like the first; after this the dressing is to be 
renewed daily. The patient should not be permitted to leave her bed for 
twelve or fourteen days after the operation. 
Obstruction from a polypus is to be overcome by the forcible removal of the 
growth. 
Tumors of the Uterus. 
The uterus is the seat of benign and malignant growths. Those which be- 
long to the benign class are the myofibromata of Virchow (fibroids of Roki- 
tansky), fibro-cystic tumors, and polypi. The malignant affections are medullary 
cancer, epithelial cancer, and sarcomata. 
Myo-fibromata of the uterus may be either single or multiple. They are 
classified according to location as intramural or interstitial, when seated deeply 
in the walls of the uterus (Fig. 1485); subperitoneal, when projecting from the 
serous surface of the organ (Fig. 1486); and submucous or intra-uterine, when 
situated beneath the lining membrane of the uterus. (Fig. 1487.) 
The usual location of these growths is in the body or in the fundus of the TUMORS OF THE UTERUS. 
767 
womb. The posterior wall of the organ is most frequently affected, the an- 
terior wall next, the lateral portions of the organ next, and the neck rarely. 
Fig. 1485. 
Fig. 1486. 
Intramural fibroma. 
Subperitoneal fibroma 
Myo-fibromata are never seen before the age of puberty, and seldom earlier 
than the twenty-fifth year. They are more common in the unmarried and 
the sterile than in child-bearing women. 
Negro women are singularly prone to 
these growths. They are often the cause 
of miscarriage and sterility. 
Pathology.-Myo-fibromata consist of 
a hyperplasia or hypertrophy of the nor- 
mal tissue components of the uterus. 
Sometimes the muscular elements pre- 
ponderate (myoma), at other times the 
fibrous (fibroma). The former are more 
vascular than the latter, and consequently 
grow more rapidly, and are less likely to 
become arrested by natural processes. 
These neoplasms are liable to degenera- 
tions, as the fatty, calcareous, cystic, car- 
cinomatous, sarcomatous, and myxomatous. 
Aneurismal dilatation of the vessels of a 
myoma, forming a kind of erectile tissue, 
is occasionally witnessed,-the telangiec- 
tasis of Virchow. 
Causes.-Although we are in possession of facts which point to some of 
the predisposing causes, as race, age, sterility, etc., nothing certain is known 
with regard to those influences which are exciting or determining. 
Symptoms.-The symptoms are rational and physical. Among the first may 
be enumerated a feeling of weight in the pelvis, menorrhagia, dysmenorrhoea, 
irritability of the bladder or rectum, and often pains in the back and down 
the limbs, owing to pressure on the sacral or crural nerves. It is not un- 
common, however, for a myo-fibroma to exist without the patient's suffering 
from any of the symptoms which have been named, particularly when the 
growth is in the substance of the womb, or is growing towards the peri- 
toneum. The physical signs are most conclusive, and these are ascertained 
by an examination conducted through the vagina, the rectum, and the ab- 
dominal walls. 768 
SURGICAL DISEASES OF WOMEN. 
In making the exploration by the vagina or the rectum, the woman is 
placed on her back, with the limbs drawn up and the thorax bent forward. 
The finger of the operator is carried up behind the cervix uteri, while the 
latter at the same time is forced down by strong pressure made with the 
other hand above the pubes, when, if any growth exists in the posterior 
wall, it will probably be discovered. 
The examination of the anterior wall requires the finger to be thrust up 
in front of the cervix, while the same pressure is made over the hypogastrium. 
If the touch cannot be made to reach the higher portions of the organ, the 
latter should be drawn down by a hook or vulsellum sunk into the cervix, 
and the digital examination repeated. Often it will be necessary to carry 
the inquiry into the cavity of the womb, sounding its depths with either 
the probe or the finger, or with both. 
If the growth is developing inward, so as to encroach on the interior 
of the womb, as in submucous fibromata, the projection, as well as its locality, 
can readily be detected with the probe. If the results of the instrumental 
exploration are not satisfactory, the canal of the cervix can be dilated by 
sponge tents and the finger introduced into the uterine cavity, and if the 
organ is drawn well down by the hook, or made to descend by forcible press- 
ure applied over the hypogastrium, the entire interior of the womb, even to 
the summit of the fundus, can be studied by the touch. The effect of these 
neoplasms is to alter the form and increase the depth of the uterus, the extent 
of which can easily be measured by the probe. 
Diagnosis.-The diseases with which uterine fibroids might be confounded 
are ovarian tumors, hcematocele, cellulitis, retroflexion, anteflexion, and fecal 
accumulations. 
The following characteristics usually belong to ovarian tumors. When 
moved in the abdominal cavity they do not impart a corresponding motion 
to the uterus, as will appear by touching the os with a finger while such 
manipulation is practiced. This fact is proved by introducing into the 
uterus the uterine probe, which will remain quiet while the tumor is rolled 
about. The only exception to the test of uterine mobility is when the ovarian 
cyst is attached to the organ, when, if the tumor is a solid one, the diagnosis 
will be very difficult. The existence of menorrhagia, and the absence of 
emaciation and of fluctuation, are signs belonging to uterine fibromata and 
unusual in ovarian cysts. In doubtful cases the aspirator can be used to 
remove obscurity. 
Hcematocele differs from a fibroma in its history, coming on suddenly and 
being sensitive to the touch, rendering the uterus fixed, and being seldom 
unattended with marked constitutional disturbance. Myo-fibromata, on the 
contrary, are slow or gradual in their formation, do not render the womb 
immovable, and for some time give rise to no constitutional symptoms. 
Cellulitis is accompanied by the usual signs of inflammatory fever, is sudden 
in its invasion, and fixes the womb, the swelling being very sensitive to the 
touch. 
Displacements of the uterus, when the organ is retroverted, form a tumor 
which can be distinctly felt through the rectum, and, if it is anteverted, 
one which is situated behind the pubes; but to differentiate these from a 
myo-fibroma it is only necessary to insert the elevator of Sims or a sound 
into the organ, when it can readily be raised or depressed from its abnormal 
place. 
Fecal impaction.-It is difficult to understand how a mass of hardened 
faeces in the rectum should be taken for a fibroma of the uterus; yet such 
an error has been committed. The depression made on an accumulation of 
fecal matter by pressure exerted through the recto-vaginal septum ought to 
leave no doubt as to its nature. 
Course of Myo-Fibromata.-Occasionally these growths attain very large 
dimensions, though generally their size varies from that of a hickory-nut to 
that of an orange. After the menopause, when the vascularity of the uterus TUMORS OF THE UTERUS. 
769 
is diminished, they frequently either cease to increase or become atrophied. 
They also become the seat of metamorphic changes which may destroy their 
structure, substituting for the latter collections of purulent or bloody ma- 
terial; and colloid degenerations have been observed. When they prove 
fatal, which may be considered an unusual occurrence, the event is induced 
by the exhaustion incident to repeated hemorrhages and to hectic symp- 
toms. 
Treatment.-While engaged in teaching practical anatomy, I noticed the 
frequency with which fibroid tumors of the uterus were found in the dis- 
secting-rooms ; in a great many instances they had evidently ceased to grow, 
or had atrophied; and it is no doubt true that in a number of cases, aside 
from some displacement or some disturbance of the menstrual function, 
no inconvenience is likely to follow the presence of such growths. As long, 
therefore, as the tumor does not increase in size, very little interference is 
demanded. 
It is the duty of the practitioner to correct as far as possible any dis- 
placement which may result, as the increase of the fibroma is stimulated by 
malposition of the uterus. During the menstrual period, the woman should 
remain quiet in the recumbent position, thus lessening the amount of blood 
circulating through the organ, and in the same proportion depriving the 
growth of pabulum. 
The remedies employed for the cure of uterine fibroids are medtcinaZ and 
operative. 
Medicinal treatment aims at effecting the removal of the disease by absorp- 
tion. Various agents have been employed for this purpose: among these may 
be enumerated iodine, iodide of potassium, bromide of potassium, bichloride 
of mercury, chloride of calcium, muriate of ammonia, ergot, and certain 
mineral waters, notably those of Kreuznach in Germany. 
Prominent among these remedies is ergot, administered by the mouth or 
hypodermically, and in sufficient quantity to maintain a gentle contraction 
of the uterine walls. It is intended by thus excluding a certain quantity of 
blood to starve the growth and arrest its augmentation, thus predisposing it 
to atrophy. The subcutaneous administration of the drug appears to be 
most efficacious, eight or ten minims of Squibb's ergotin being inserted into 
the cellular tissue of the abdomen every day or two for eight or ten weeks. 
In some instances I have seen the tumor noticeably diminished or arrested 
in its growth. In others, no change could be discovered. One important 
effect, however, wfill be produced by the use of ergot, viz., the diminution or 
entire control of hemorrhage; and this is a positive gain. The influence 
of hot water in lessening the circulation of a part may be utilized in the 
treatment of fibroids by daily using hot vaginal injections. The late Dr. 
Atlee attributed considerable absorbent power in these affections to the mu- 
riate of ammonia exhibited for a long time in seven- or eight-grain doses. 
Bromide of potassium, when the nervous system of the patient is much 
unsettled, will fulfill a valuable indication as a sedative. Simpson believed 
that this drug exercised some curative power over uterine fibroids, and gave 
it with this end in view. 
To control hemorrhage, so often an attendant of these growths, the usual 
haemostatics can be employed, as gallic acid, ergot, etc. Opium and the tinc- 
ture of cannabis Indica, so much lauded by Churchill and McClintock, may 
be given with decided benefit, which results from the power they possess 
of allaying constitutional and local irritation. Emmett has obtained capital 
results in cases of obstinate bleeding by dilating the canal of the cervix and 
injecting into the womb hot water by means of a long nozzle attached to a 
Davidson syringe and passed into the organ. 
Electrolysis has been employed for the cure of uterine myomata, the needles 
being passed into the substance of the tumor. Evil oftener than good fol- 
lows this treatment. 
Operative measures are adopted sometimes for the purpose of arresting hem- 
vol. ii.-49 770 
SURGICAL DISEASES OF WOMEN. 
orrhage, and at other times for the removal of the tumor. When the object 
is to control bleeding, the cervix is divided laterally by the scissors,-an 
operation introduced by Nelaton, and used by Baker Brown, the purpose 
of which is to secure the contraction which takes place in the walls of the 
uterus when blood is abstracted from its vessels. The bleeding following 
this operation will often require the tampon for its arrest. 
Submucous myo-fibromata projecting into the cavity of the uterus are sus- 
ceptible of removal, as indeed are those also which are subperitoneal and 
pedunculated. The first class are to be treated by enucleation or by ecrase- 
ment, the latter operation being applicable only to cases in which the growth 
has a base narrower than its body. 
Enucleation, first practiced by Amussat in 1840, though previously sug- 
gested by Velpeau, is an operation based on the fact that these growths are 
generally surrounded by a wall of loose connective tissue. 
In removing a submucous fibroid, the neck of the uterus must be gradu- 
ally well dilated by sponge tents, or rapidly by the instrument of Molins. 
In effecting dilatation by tents (Fig. 1488), the neck of the uterus should be 
exposed by the speculum and steadied by fixing in it a long tenaculum or 
Fig. 1488. 
Sponge tent. 
hook, while the tent, held either in the grasp of a special forceps (Fig. 1489) 
or by a director (Fig. 1490), is introduced into the canal of the cervix. The 
Fig. 1489. 
Tent-forceps. 
Fig. 1490. 
Tent-director. 
dilatation can usually be sufficiently accomplished by two tents; and it is 
desirable that, if possible, not more should be used, as the danger increases 
•with each renewal. The work will be hastened by preceding the use of the 
tent with the dilator, as thereby a larger sponge can be introduced. When the 
dilatation has been completed, a free incision is made through the capsule of 
the tumor and some distance into its substance with a blunt-pointed bistoury, 
while the uterus is drawn strongly down by a vulsellum. This done, a finger 
or a curette (see Fig. 1499) will often be quite sufficient to shell out the mass, 
when it can be extracted through the os. 
Emmett, in executing an enucleation, arms the finger with a steel instru- TUMORS OF THE UTERUS. 
771 
ment having a serrated edge. Thomas effects it by means of a spoon-saw or 
scoop (Fig. 1491), with which he separates the attachment of the fibroid, 
Fig. 1491. 
Thomas's spoon-saw. 
whether it be mural or submucous. Goodell slips over the tumor a wire 
ecraseur, and with this divides the capsule on a level with the wall of the 
uterus; after which, by seizing the growth with a vulsellum, and using both 
instruments as tractors and levers, the neoplasm is wrenched from its bed 
and extracted. 
In order to gain access to intra-uterine fibroids, the neck of the womb 
is sometimes incised. When this plan is adopted, the operator should not 
attempt the extraction of the tumoi' until the wound in the cervix has 
healed. 
Enucleation is not unattended with danger. The wall of the uterus may 
be perforated, when the tumor is deeply imbedded in its substance, or the 
patient may perish from peritonitis or pyaemia. Of 28 cases of this opera- 
tion recorded by West, 14 proved fatal. 
When enucleation is impossible, the growth may be excised piecemeal by 
the tenaculum and scissors. 
Ecrasement.-When the fibroid offers a base sufficiently narrow to admit of 
being crushed off, the chain of an ecraseur (Fig. 1492) should be passed around 
the pedicle; then by turning the screw of the instrument the attachment is 
Fig. 1492. 
Ecraseur. 
gradually severed. I sometimes use piano-wire (Fig. 1493) as a substitute 
for the chain. 
Fig. 1493. 
Wire ecraseur. 
It is occasionally a difficult task to adjust the chain of the ecraseur around 
the pedicle of a uterine growth: the least complex device for the purpose is 
a simple fork (Fig. 1494), or the porte-chavne of Sims will be found to answer 
the same purpose. 772 
SURGICAL DISEASES OF WOMEN. 
When wire is used, neither of these instruments will be required, as the 
loop will retain a sufficient degree of rigidity to admit of its being carried 
into position without any artificial aid, except per- 
haps that of a forked probe. 
Incision.-Fibroids have been successfully attacked 
by making incisions through their capsules, thus ex- 
citing sloughing, and then by the free use of ergot 
favoring the expulsion of the mass from the womb. 
Uterine contraction constitutes an important ele- 
ment in the dislodgment of fibroids. Twice have I 
seen large tumors of this nature spontaneously ex- 
pelled from the walls of the womb in this way with- 
out any preliminary incision or other operation. 
Subperitoneal myo-fibromata, as a rule, admit of no 
operation for their removal; though if there is reason 
to believe that the growth is pedunculated, and the 
patient's condition is rapidly growing worse, she is 
not to be denied the benefit of an attempt to extir- 
pate the disease. It is probable that the application 
of antiseptic treatment in uterine surgery will render the operation more 
popular than it has heretofore been. 
In ordei' to remove a subperitoneal myo-fibroma the abdomen must be 
opened in the median line, as in ovarian operations. The tumor being ex- 
posed and its serous covering divided, it should, if possible, be shelled out of its 
bed, and, after the control of all bleeding, the wound in the parietes of the 
abdomen should be closed, as is done after ovariotomy. If the tumor has a 
narrow pedicle it can be severed by the wire ecraseur, any vessels which con- 
tinue to bleed being tied by the carbolized thread or sealed by the point of a 
cautery. In a case of an enormous fibroid, larger than a man's head, which 
I removed by abdominal section from a patient in the Pennsylvania Hos- 
pital, the pedicle was three inches in length and three inches in circum- 
ference, the entire growth resembling a large head of cabbage with the stalk 
attached. The pedicle, which was exceedingly vascular, was clamped and 
brought into the wound in the abdominal walls. The patient died on the 
third day following the operation, from exhaustion. 
When, on opening the abdomen, the growth is found to involve a large 
portion of the womb, the operation will have to be abandoned, or the uterus 
extirpated. The latter is a formidable procedure, entailing a shock so tremen- 
dous, and being followed by so many dangers,-inflammatory and infectious, 
-that only in cases of extreme urgency is it justifiable to undertake it. 
The results of operations for the removal of uterine fibromata and cysto- 
fibromata, as presented by different writers, are somewhat conflicting. 
What antisepsis may accomplish in diminishing the mortality remains to be 
determined; but in the light of present statistics no operator would desire, 
except under very peculiar circumstances, to engage in this undertaking. 
When such an operation is contemplated, the extirpation of the uterus along 
with the tumor will offer a better prospect of recovery than the attempt to 
remove the disease alone. 
Of 119 cases collected by Polli, 77 proved fatal. 
Spencer Wells,* in summing up his experience in the surgical treatment 
of uterine tumors by operations through the abdominal walls, gives us an 
analysis of 45 cases, in 24 of which the tumors were completely removed, 
and in 21 only exploratory incisions were made or the growth partially 
extirpated. Of the 24 cases, 15 died at various intervals between the third 
and the fourteenth day following the operation, and 9 recovered. One of 
these nine died six months afterwards from cancer of the remaining part 
of the uterus. 
Schroeder'sf analysis of cases of laparotomy for the removal of uterine 
Fig. 1494. 
Fork for conducting the chain 
of the ecraseur around a fibroid. 
« British Medical Journal, July 27, 1878, p. 129. f Ziemssen's Cyclopaedia, vol. x. p. 255. UTERINE POLYPI. 
773 
fibroids is more encouraging. His collection amounts to 108, with 78 deaths 
and 30 recoveries, or 27.8 per cent. In 73 of the 108 cases the uterus was 
removed along with the tumor, followed by 55 deaths and 18 recoveries, or 
24.66 per cent. In the 35 remaining operations in which the tumor alone 
was extirpated, there were 23 deaths and 12 recoveries, or 34.3 per cent. 
Duplay's laparatomies* for the removal of fibromata aggregate 17 cases in 
which the tumor was removed without the uterus, with 5 cures and 12 
deaths; 56 cases in which the uterus was extirpated with the fibromata, with 
24 cures and 32 deaths; and 41 removals of the uterus along with cysto- 
fibromata, with 22 cures and 19 deaths. We have, therefore, 170 laparotomies 
in which both uterus and fibroid were removed, with 64 cures and 106 
deaths; and 52 in which the tumor alone was removed, with 25 deaths and 
15 cures. 
Cysto-Fibromata.-Cystic growths of the uterus are very frequently con- 
founded with ovarian tumors. A tumor of the uterus originally solid-for 
example, a myo-fibroma or a sarcoma-may undergo cystic degeneration ; 
that is, there are formed in the neoplasm one or more cavities, which become 
lined with a smooth, secreting membrane. The initial excitant of the cyst is 
sometimes an apoplectic clot, sometimes a mucoid degeneration of the con- 
nective tissue, and at other times an inflammatory infiltration, which results 
in a purulent fluid. 
Cysto-fi brom ata are not very common growths; indeed, until a compara- 
tively recent date the disease had no place in gynaecological literature. They 
have been particularly noticed by Cruveilhier, Lee, Spencer Wells, Atlee, 
Thomas, Peaslee, and Emmett. 
These cysts are oftener encountered in the subserous than in the mural 
and submucous variety of myo-fibromata. They often grow with the same 
rapidity as an ovarian cyst, and acquire enormous dimensions, filling up the 
entire abdomen. 
The diagnosis of a fibro-cystic tumor can only, as stated by Atlee, be de- 
termined by tapping. The fluid has a yellow color, is ropy in its consistency, 
and coagulates or becomes gelatinous after being drawn off, the coagulum 
having a whitish appearance. 
Treatment.-The treatment for the most part is palliative, and consists 
in tapping the tumor when the cyst becomes so large as to interfere with the 
comfort of the patient. An operation for the removal of the disease offers 
very little prospect of success. 
Uterine Polypi.-Polypi of the uterus covered by mucous membrane are 
very common growths, and present different appearances according to the 
preponderating element in their structures. It would be well if the term had 
a more restricted signification than is usually accorded to it. Three varieties 
of these growths may be recognized,-the fibro-myomatous, the mucous, and 
the adenoid. These growths are often essentially submucous fibroids. 
Fibro-myomatous polypi.-This variety is in all respects, except in form, 
identical with the fibro-myomata of the uterus, commonly described as uterine 
fibroids. They consist of interlacing fibres of connective tissue, have a pale, 
grayish-white color, and a firm, elastic feel, are pyriform or globular in shape, 
and are usually attached to the interior of the body of the uterus by a ped- 
icle, which may be long, short, slender, or thick. The weight of the growth 
has a tendency to increase the length, and also the tenuity, of the pedicle. 
These tumors vary in size from that of a pea to that of a cocoa-nut. 
Mucous polypi present a grayish, translucent appearance, have a soft, gelat- 
inous consistency, and a long, slender pedicle, which often allows them to 
escape from the uterus, remaining suspended in the vagina, or even hanging 
out of the vulva. They are made up of scattering threads of submucous 
connective tissue, a few straggling vessels, and a mucoid substance which 
* Reported by letter from Dr. Harris. 774 
SURGICAL DISEASES OF WOMEN. 
renders the mass tremulous and changeable under different atmospheric con- 
ditions. Its attachment is generally at the neck of the uterus. (Fig. 1495.) 
Adenoid polypi.-The adenoid or glandular 
polypus originates in the Nabothian glands 
of the cervix and cavity of the womb. These 
follicles become enlarged and dilated into 
small sacs. A group being simultaneously 
affected, the members of which are held to- 
gether by connective tissue, and contain nu- 
merous blood-vessels, and probably muscular 
fibres, forms one or more pedunculated tumors 
of a reddish or a gray color, the size of a 
cherry, having a tabulated appearance, and 
suspended by one or several slender pedicles. 
These growths are covered with a smooth 
membrane, and contain metamorphosed mu- 
cus with the normal epithelium of the gland- 
tissue. 
Polypi differ in vascularity, the degree of 
which can be determined by the color of the 
growth, which has a red appearance when 
abundantly supplied with blood. The mucous 
variety are generally more abundantly sup- 
plied with vessels than the fibro-myomatous. 
Other varieties have been described by writers, as the channeled and tubular 
polypi, distinctions founded on the presence of a hollow or canal existing in 
the growth. Fibrinous polypi originate, it is thought by Krenisch, from a 
blood-clot contracting and attaching itself to the inner surface of the uterus 
and becoming organized. Malignant and calcareous polypi, the former re- 
curring tumors, the latter metamorphoses, with the salts of lime deposited 
in their structure, are also described by various authors. 
Symptoms.-Uterine polypi, in consequence of the congestion which they 
produce, give rise to hemorrhage, menorrhagia, and leucorrhoea. Sometimes 
they block the internal os or the cervix uteri, obstructing the flow of the 
menses, and thus becoming a cause of dysmenorrheea. 
The physical signs are alone reliable. When the growth is attached to the 
surface it can often be discovered, on exposure of the parts by a speculum, 
lying in the os or projecting into the vagina, suspended by a narrow pedicle 
from the cervical canal. In many instances the vagina is found filled with 
the growth, which, through its action as a wedge and with the aid of the 
uterine contractions, has gradually dilated the neck of the womb and escaped 
from its cavity. 
If the polypus is not visible in the neck of the womb, and if there are evi- 
dences of its existence within the body of the organ, the diagnosis may be 
established by the probe and the finger, the latter always to be preferred. 
To render the digital examination practicable, the neck of the uterus must 
be dilated with sponge tents until the finger can be carried into its cavity, 
when the shape of the growth and the point of attachment can be determined. 
The evils which attend the presence of a uterine polypus are ansemia and 
exhaustion from the loss of blood, endometritis, and sometimes displacements 
of the womb. 
Treatment.-When the polypus is seen either in the cervix or in the vagina, 
it should be removed without delay. This can be done in several ways. 
Torsion.-If the pedicle is not too thick, the tumor is most expeditiously 
disposed of by torsion, seizing the growth as near as possible to its attach- 
ment with a pair of strong polypus forceps (Fig. 1496) and twisting it round 
and round until it is detached from its connection with the cervix. In doing 
this the manipulation is often facilitated by sinking a hook into the neck 
of the womb and fixing it while torsion is made. 
Fig. 1495. 
Mucous polypus attached to the cervix by a 
slender pedicle. UTERINE POLYPI. 
775 
Ecrasement.- When the pedicle is thick, strong, and fleshy, it will be 
divided with the greatest facility by means of either the wire or the chain 
Fig. 1496. 
Uterine polypus forceps. 
ecraseur, or by the mackerel-bill ecraseur of the author. (Fig. 1497.) Gen- 
erally there is not much difficulty in adjusting either of these instruments; 
Fig. 1497. 
Author's ecraseur. 
but if the contrary is the case the surgeon can resort to the contrivances 
employed for carrying the chain or wire described under the head of uterine 
fibroids. 
Excision of a polypus is sometimes preferred; and when the growth is 
small, this operation is performed by seizing the tumor with a vulsellum and 
snipping the pedicle with a pair of long scissors; or it can be severed by 
Hodge's sickle-shaped polypotome. (Fig. 1498.) Multiple growths of this 
Fig. 1498. 
nature which do not rise far above the surface and do not admit of torsion 
or crushing should be removed by scraping, or by the curette. (Fig. 1499.) 
Hodge's polypotome. 
Fig. 1499. 
Uterine curette. 
When the polypus occupies the interior of the body or the fundus of the 
uterus, the difficulties of the case are greatly enhanced, especially if the 
tumor is broadly attached. I have seen nature come to the aid of the prac- 
titioner in so many cases of this kind, that I question very much the pro- 
priety of any operative interference so long as the health of the patient is 
not seriously implicated. 
The uterine contractions which are provoked by these polypi tend to 
pedunculate the growth, so that in time a somewhat sessile base will become 
converted into a pedicle and the body of the tumor will be thrust into the 776 
SURGICAL DISEASES OF WOMEN. 
vagina, rendering its extraction by torsion or by ecrascment an easy task. 
Indeed, the tumor may, by the above process, be completely separated from 
all its uterine connections and be extruded from the cavity of the womb 
entire. It is astonishing with what persistence some of these growths, under 
atmospheric pressure, cling to the vagina after leaving the uterus. In a lady 
whom I saw with the late Professor John Neill, a fibroid polypus which had 
existed for a long time had finally been delivered by the spontaneous efforts 
of the uterus. It was perfectly round, resembling a billiard-ball, and the 
size of a foetal head. It lay in the vagina, and, although entirely disengaged 
from all the surrounding parts, the most powerful tractions by vulsellum 
forceps failed to extract it. No obstetric forceps being at hand, it was 
finally removed by passing a lever behind the tumor and forcing it forward, 
while at the same time all the force at command was exerted in the way of 
traction. 
Until a case becomes urgent, it will be best to treat it tentatively, by at- 
tending to the state of the bowels, and forbidding all violent muscular efforts 
or active exercise, especially during the menstrual periods, at which time 
the woman should be kept in bed, or at least in the recumbent position; all 
excess in the menstrual flow should be controlled by the use of ergot, gallic 
acid, opium, or aromatic sulphuric acid; any displacement which may exist 
should be corrected; and the effects of the exhausting menorrhagia should 
be counteracted by a nutritious diet and the preparations of iron, ergot, and 
quinia. 
When operative measures cannot be longer delayed with safety to the 
patient, the canal of the cervix uteri must be dilated by tents to a degree 
which will admit the finger, thus enabling the surgeon to ascertain the posi- 
tion of the tumor and the nature of its attachment, when, if the polypus is 
pedunculated, it can be twisted off with the uterine polypus forceps, guided 
by the finger; or, seized by a double tenaculum (Fig. 1500), it may be drawn 
down and its base surrounded with the wire ecraseur and crushed off. 
Fig. 1500. 
Vulsellum tenaculum. 
The galvano-cautery can also be used with great advantage when the wire 
belonging to the battery can be safely placed around the base of the tumor. 
By this method the vessels are sealed and hemorrhage prevented at the 
same time that the parts are divided. The Byrne battery will fulfill this 
purpose admirably. 
If the attachment of the tumor is too broad to be thus treated, the greater 
part may be cut away with the hook and scissors. In these last cases some 
advise making deep incisions into its structure, trusting to its subsequent 
disintegration and expulsion. This course is not without danger. The life 
of a patient is greatly jeopardized by the mass of decomposing material 
retained within the womb. In the only instance in which I adopted this 
plan the patient perished from pyaemia. 
Ligation.-The same objection, though not with equal force, may be urged 
against ligation,-that is, surrounding the pedicle with a wire passed through CARCINOMA OF THE UTERUS. 
777 
a double canula (Fig. 1501) and tightening the same until the base of the 
polypus has been cut through. Decomposition soon follows the contraction, 
Fig. 1501. 
Gooch's canula. 
and exposes the woman to septic poison. In 59 eases treated by ligation and 
collected by Dr. Lee, of London, 9 died. 
The hemorrhage which follow's the removal of uterine polypi, if protracted, 
can be checked by hot water passed into the uterus, by full doses of ergot 
given internally, or, if very profuse, by the tampon. 
Carcinoma of the Uterus. 
Carcinoma of the uterus, except so far as it may be modified by structural 
peculiarities, does not differ from the same disease in other parts of the body. 
It is met with chiefly in two forms, encephaloid and epithelial. Scirrhous and 
colloid varieties of the disease are quite uncommon. Cancer of the uterus is 
very common. In 8746 cases of cancer analyzed by Simpson, 300 occurred 
in the uterus. Its frequency, as compared with that of other diseases inci- 
dent to females, may be learned from the statement of Emmett, that of 2153 
females admitted to the Woman's Hospital of the State of New York, 60, or 
2.78 per cent., suffered from malignant diseases of the uterus. 
The predisposing causes of cancer of the uterus are somewhat obscure. In 
many instances the hereditary origin of the disease cannot be doubted, but 
in others no antecedent history of this kind can be discovered. In 729 cases 
of uterine carcinoma, which embrace the collections of Lebert, Paget, and 
Sibley, as recorded by Thomas, only 125 could be referred to hereditary 
causes. 
Age exerts a very marked influence on the appearance of the disease. It 
is never seen before puberty, or earlier than the twentieth year, the largest 
number of cases occurring between 36 and 46 years of age. Scanzoni, in 108 
cases, found 45 of the patients between 35 and 45. According to the obser- 
vation of the same writer, women who have borne several children are more 
commonly the subjects of uterine cancer than those who have been fruitless; 
and the testimony of Emmett and other gynaecologists is to the same effect. 
The influence of regular sexual indulgence is most clearly traced in the com- 
parative statistics of Clatter.* According to these, out of 1000 healthy 
Vienna women over twenty years old 459 were single, 408 married, and 
133 widows; w'hile out of 1000 Vienna women with cancer of the uterus 229 
were single, 503 married, and 268 widows. 
Race is believed also to exercise some predisposing influence on the disease. 
In evidence of this, the comparative exemption of the black race is adduced 
by Professor Chisolm. 
Little is known with regard to the exciting causes of uterine cancer. 
Encephaloid carcinoma of the uterus is frequently met with. In 34 speci- 
mens of malignant disease of this organ examined by Cornil and Ranvier, all 
were examples of this variety of cancer. The disease often makes considerable 
progress before being suspected by the patient, the only sign of any disorder 
of the womb being a watery or bloody discharge, and this may occur in 
women who, far from being broken in health, present unusual evidences of 
* Ziemssen's Cyclopaedia, vol. x. p. 275. 778 
SURGICAL DISEASES OF WOMEN. 
a vigorous nutrition. The disease begins in the submucous tissue of both 
the uterine and the vaginal surface of the os, near to or at its free border, 
in the form of an induration and hypertrophy. Generally one lip is first 
affected, and then the other. Vascular granulations soon appear after the 
mucous membrane has undergone ulceration, and are followed by erosion 
and dilatation of the outlet of the canal, giving to the os an excavated, patu- 
lous appearance. The granulations and induration extend, until the entire 
neck of the womb is buried in the vegetations, which bleed on being touched, 
and from which a blood-stained watery fluid, like the washings of raw beef, 
and having an offensive odor, is discharged, often soaking five or six cloths a 
day. On making a digital examination, the finder comes in contact with an 
irregular friable growth, which having once been felt will scarcely ever be 
forgotten. In these examinations the greatest gentleness of touch should 
be observed, as by rudely breaking through the granulations a large amount 
of blood may be lost. When the growth is exposed to the eye by the careful 
use of a speculum, there will be seen a red, irregular, granular, and fungous 
mass of vegetation. 
When the infiltration attacks the neck and the body of the uterus simul- 
taneously, it often provokes an inflammatory infiltration of the cellular 
tissue of the pelvis, which, pressing on the sacral nerves, occasions severe 
pain in one or both hips and down the backs of the thighs. This symptom 
is sometimes the very first complained of, and should always, when severe 
and persistent, and when observed in women about or after the menopause, 
excite suspicion of malignant disease of the womb. 
Epithelioma commences on the surface of the cervix. Its course is very 
different in different individuals. Sometimes it is quite rapid in its progress, 
at other times it is slow, lasting for five or six years before threatening life. 
Pathologists recognize two varieties of epithelioma, the distinction consisting 
in the form of the cells constituting the growth, namely, the pavement-celled 
and the cylindrical-celled epithelioma. The particular variety of the disease 
will be determined by its locality. If it begins on the vaginal surface of the 
neck of the womb, where the normal epithelial cells are arranged in pave- 
ment-like layers, the cancer will be a pavement-celled epithelioma; and it is 
this form which is most common. If the disease begins on the mucous sur- 
face of the cavity of the cervix, where the cells are naturally cylindrical, it 
will be a cylindrical-celled epithelioma. The latter variety resembles enceph- 
aloid cancer, the vegetations being soft and moist, the disease showing a 
marked tendency to infiltrate the adjoining tissues, and often running its 
course rapidly. Examined microscopically, the diseased formation exhibits 
tubes and pearly bodies filled with epithelia. The anatomical appearances 
are also not unlike those of an encephaloid growth, viz., a soft juicy mass 
containing alveoli, filled with round cells, circumscribed by fibro-muscular 
tissue, and on which blood-vessels ramify. 
In the pavement-celled epithelioma the granulations are small, never luxu- 
riant, furnish little discharge, gradually excavate and destroy the cervix by 
erosion or ulceration, and manifest little disposition to infiltrate. This 
variety of epithelioma answers to the corroding ulcer of Clarke, of London. 
Epithelioma appears somewhat later in life than encephaloid cancer, not being 
common earlier than the forty-fifth, and often being seen after the sixtieth, 
year of life. 
The pain in carcinoma of the uterus is frequently severe, and possesses the 
quality of lancination so characteristic of malignant disease. This pain is 
not felt alone in the pelvis about the neck of the womb, but frequently shoots 
down the limbs, into the rectum, and upward towards the loins. Generally 
the suffering is less in encephaloid than in epithelial carcinoma. The phy- 
sician will see cases where no pain, or very trifling pain, is experienced from 
the commencement to the termination. 
Though the general health appears to be unimpaired at first, the signs 
of constitutional deterioration finally begin to appear. The patient loses CARCINOMA OF THE UTERUS. 
779 
flesh and strength, the appetite fails, the face has a waxy or dirty, sallow 
appearance, and death ensues either from septicaemia or exhaustion. 
Diagnosis.-It is possible for carcinoma of the uterus to be confounded with 
papilloma and syphilitic ulceration. But an error of this kind may be avoided 
by considering that in the former affection there is induration of the uterine 
tissue, with often a free flow of a sanious or watery discharge. In syphilitic 
sores, the antecedent history, the other evidences of venereal origin, and 
the rapid improvement under specific treatment will serve to distinguish the 
disease. 
Duration.-The duration of carcinoma of the uterus does not, as a general 
rule, exceed two years. I have seen exceptional instances in which the 
disease pursued a very chronic course, lasting for five years before the fatal 
issue. 
Treatment.-When the disease is limited to the lower portion of the 
cervix, leaving a sufficient amount of apparently sound tissue between the 
growth and the insertion of the vagina, the neck should be removed without 
delay. This can be done by the galvano-cautery wire, by the chain, or by 
the wire ecraseur. 
Should the bleeding consequent on the operation be too free, it can be 
quickly arrested by the thermo-cautery of Paquelin, or, in the absence of 
anything better, by the tampon. After the amputation of the neck and the 
control of hemorrhage, the most suitable dressing is a pledget of absorbent 
cotton soaked with glycerin to which a few drops of carbolic acid have been 
added. Emmett advises covering the raw surface with the vaginal tissue 
and stitching it with sutures to the neck before applying any dressing. 
When the disease has involved the entire vaginal portion of the neck, the 
woman must be either abandoned to her fate or the part removed after the 
plan of Schroeder, by seizing the cervix -with a vulsellum forceps or a hook 
and removing all the diseased portion, with some sound uterine tissue, by a 
funnel-shaped incision. The above-named writer says he has performed this 
operation two hundred times without a death, and has succeeded in curing 
many cases. 
When the body of the uterus has been attacked, the surgeon should be 
content with using palliative measures. These include both constitutional 
and local treatment. The first will embrace tonics, especially iron in some 
of its forms, quinine, arsenic, and highly nutritious food, with stimulants. 
The local measures are to be directed to deodorizing and disinfecting the 
discharges which flow into the vagina, and moderating or preventing hemor- 
rhage. To this end nothing conduces more than carefully scraping away 
with a uterine curette (Fig. 1499) the rotten granulations down to the proper 
tissue of the neck, or to the body of the womb, when the disease occupies it, 
and subsequently using vaginal injections of solutions of permanganate of 
potash or nitrate of lead, or Monsel's solution of iron much diluted (one drachm 
of the salt to six ounces of water). 
Extirpation of the uterus on account of cancer has been frequently per- 
formed, but, as the disease is almost sure to return, it is difficult to understand 
the reasons which prompt such a procedure. For results, see Extirpation 
of the Uterus. 
Sarcoma, though histologically different from carcinoma, is also among the 
malignant affections of the uterus. The disease exhibits a singular partiality 
for the neck of the womb, extending gradually to the body of the organ, 
though occasionally the reverse is true, the body being first attacked and 
the morbid action spreading downward. Malignant disease of the uterus often 
extends to the bladder, rectum, vagina, and ovaries, giving rise to fistulfe. 
It is quite uncommon, and when it does occur it is at an earlier age than 
is usual with cancer, and is perhaps more frequently met with among sterile 
than among fruitful women. The disease is frequently mistaken for fibro- 
myomata and polypi; and, indeed, so close is the external resemblance 780 
SURGICAL DISEASES OF WOMEN. 
to the latter that often nothing short of a microscopic examination will be 
adequate to establish the distinction. When subjected to this test, uterine 
sarcomata will be found, when laid open, to present a white appearance, and 
to consist of a granular matrix containing spindle-form cells and nuclei. 
These neoplasms, when removed, are likely to reappear: hence the name 
recurrent fibrous, applied to them by Mr. Paget. As these growths increase 
they finally ulcerate, sending out a luxuriant crop of spawny granulations, 
which bleed profusely and discharge an ichorous, offensive fluid, exhausting 
the patient and giving rise to septicsemic infection. 
Treatment.-Operations for the removal of sarcomatous tumors are exceed- 
ingly unsatisfactory, as it is scarcely possible to extirpate the whole of the 
diseased structure, even under the most favorable circumstances, and con- 
sequently its rapid reformation may be looked for. Something, however, 
may be gained by an operation in lessening the hemorrhage and thereby 
prolonging life; and when the bleeding is copious and the growth quite ac- 
cessible, its extirpation is not to be declined. The constitutional measures 
proper in a case of this disease are tonics, a good diet, and rest in the recum- 
bent position. Locally, benefit will be derived from vaginal washes contain- 
ing tannic acid, Monsel's solution of iron, alum, nitrate of lead, bromine, or 
permanganate of potash. 
Elongation of the Cervix Uteri.-Occasional instances of hypertrophic elon- 
gation of the neck of the uterus are seen in which this part of the organ 
reaches the external orifice of the vagina without any prolapse existing. In 
one case which was sent to me for treatment, the elongated cervix, when not 
turned back behind the pubes, protruded between the nympbaj, and was sup- 
posed to be a polypus. These hypertrophic elongations of the neck, when 
excessive, give rise to displacements of the uterus, sterility, ulceration of the 
os, and obstinate leucorrhcea, with other vaginal irritation. 
Treatment.-When the hypertrophy is sufficiently great to be a source 
of annoyance to the patient, amputation of the neck will be proper. I 
have been twice compelled to perform this operation in order to give relief 
from the mental and physical disturbance which the elongation produced. 
The amputation is most conveniently and safely executed by the galvano- 
cautery wire. When the battery is not at hand, the chain or the wire 
ecraseur, especially the latter, can be advantageously substituted. It is readily 
applied by exposing the parts with the Sims speculum, seizing the cervix 
with a tenaculum and drawing it down sufficiently far to admit of a ready 
adjustment of the wire. In the use of the ecraseur care must be taken not 
to apply the chain or the wire too near the insertion of the vagina on the 
cervix, as the instrument may draw in the tissues to an extent which will 
endanger the peritoneum by opening the cavity of the pelvis. This can be 
avoided either by transfixing the cervix with a stout pin above where the 
chain or wire encircles it, or by allowing for this tendency in the adjustment 
of the ecraseur one-third as much as the length of the tissue to be removed; 
that is to say, in amputating one inch of the cervix the instrument should 
embrace, when applied, two-thirds of an inch of the neck. The stump which 
is left should always, after the method of Sims in amputation of the cervix, 
be covered by flaps taken from the tissues of the vagina, which are to be 
stitched around the margin of the os with silver sutures. The proper dressing 
is a pledget of absorbent cotton moistened with carbolated glycerin. 
Extirpation of the Uterus. 
The removal of the uterus may be required on account of malignant 
growths or of fibroid or fibro-cystic tumors, or in cases demanding the Caesa- 
rean section. The operation is among the most formidable in surgery, and 
may be accomplished either by the abdominal section or through the vagina. 
Extirpation through the abdomen.-The method adopted by Dr. Freund, of EXTIRPATION OF THE UTERUS. 
781 
Breslau, if carried out under the antiseptic spray, is in many respects the 
most satisfactory. The patient, having been placed under an anaesthetic, is 
laid on a narrow table facing the light, with the hips raised, and the head 
and shoulders low. An incision is made in the linea alba, between the um- 
bilicus and the symphysis pubis, through the abdominal walls. The intestines 
are drawn up out of the pelvis and covered with a soft, carbolized piece of 
cloth. In order to obtain command over the uterus, a strong cord is passed 
through the fundus of the organ and tied in a loop, by which it can be pulled 
up out of the cavity of the pelvis. This done, the broad ligaments are tied 
in three sections by three strong ligatures on each side of the uterus, thus in- 
cluding the Fallopian tubes, the round ligaments, and the arteries. The body 
of the organ is now severed from its connection with the vagina and removed, 
after which the ends of the ligaments are brought through the opening 
into the vagina. (Fig. 1502.) As they are drawn upon, the stumps of the 
broad ligaments are 
made to project into 
the same opening, when 
their peritoneal edges 
are stitched together 
by a number of inter- 
rupted sutures, thus 
protecting the abdom- 
inal cavity from the 
intrusion of septic or 
other matters from the 
vagina. Schroeder, in 
removing the uterus, 
leaves the vaginal por- 
tion, and when this can 
be done, a clamp can be 
applied to the cervix 
before cutting away the 
body of the organ, as 
was done by Dr. Walter 
F. Atlee, and also by myself. 
Extirpation of the uterus by abdominal section was first performed by 
Langenbeck, and in this country by Dr. Briggs, of Kentucky. 
Operation through the vagina.-This operation was first carried into effect by 
Blundell, who performed it four times for cancer. In effecting the extirpa- 
tion per vaginam, the neck is seized by a vulsellum, and dragged down low 
into the vagina, when the latter is dissected away from the anterior semi- 
circumference of the cervix. While the neck is still grasped and drawn down, 
a finger is introduced into the opening, and the peritoneum separated from the 
anterior part of the organ. After this, the broad ligaments, being brought into 
view, are to be included in ligatures. All bleeding being arrested, the fundus 
of the uterus is to be antevertcd and drawn through the opening into the 
vagina by means of a hook, when its posterior attachments are readily 
separated by the fingers and scissors or knife. Henning, of Leipsic, has 
also made a complete ablation of the womb in this manner on account of 
cancer. 
The results of extirpation of the uterus for fibroids, for fibro-cystic tumors, 
and for cancer will appear from the following summary of cases, comprising 
most of those wThich have been recorded at different times in the various 
medical journals:* 
Storerf has collected 24 cases, of which 6 were successful and 18 fatal. In 
all of these patients the operation was done for fibroids and fibro-cystic 
Fig. 1502. 
The three divisions of the broad ligaments included in the three ligatures, 
showing also the opening left in the upper part of the vagina after cutting 
away the uterus, with the three ligatures drawn through into the vagina. 
* Dr. Baum's manuscript statistics. 
f American Journal of the Medical Sciences, January, 1866, p. 110 782 
SURGICAL DISEASES OF WOMEN. 
growths. Wood* has collected 33 cases, 7 of which were successful and 
26 fatal. Routhj- gives 48 cases of fibroid tumors. In 15 of these no attempt 
was made to extirpate the uterus. In 33, in which the uterus was removed 
entire or in part, 23 recovered and 10 proved fatal. KoeberleJ states that the 
known cases of extirpation, with or without the removal of both ovaries, 
amount to 42, with 8 recoveries and 34 deaths. Kimball's§ individual cases 
amount to 12, with 6 successes. Demarquay's|| cases were 12 in number, 
with 6 recoveries. gives 42 cases of total extirpation for fibroid, 
fibro-cystic, multilocular cysts, etc.; 10 of these were successful and 32 fatal. 
Pean's cases amount to 20, with 15 cures and 5 deaths. Total, 218 cases, 
with 81 recoveries and 137 deaths, or a death-rate of 62.84 per cent. 
The operation of extirpating the uterus through the vagina furnishes the 
following results: 
For fibroids, 2 cases, both married women, 2 successful; for cancer, 38 cases, 
11 successes and 17 deaths. In two of the successful cases one ovary was 
removed with the womb. The total number is 40, with 17 deaths, 13 recov- 
eries, and 10 in which the termination is unknown. 
The prevailing causes of death after removal of the uterus are hemorrhage, 
shock, and peritonitis. When among those operated on for cancer the result 
is given as successful, it must be understood as applied to the recovery after 
the operation. None of the patients were kept under observation longer 
than eight months. Doubtless in many instances the disease recurred. 
DISEASES OF THE OVARIES. 
Ovaritis. 
Ovaritis, or inflammation of the ovaries, is in most instances a disease of the 
puerperal state, and, unless from traumatic injury, is rarely idiopathic, but, 
in consequence of the nervous, vascular, and structural relations between 
these glands and the uterus, occurs as a secondary result of uterine dis- 
turbances, both functional and organic. 
Though the ovaries are not, strictly speaking, covered by the peritoneum, 
their close proximity to that membrane predisposes them to inflammatory 
attacks in cases of peritonitis. In like manner their contiguity to the con- 
nective tissue of the pelvis explains the extension of inflammation to those 
organs during an attack of pelvic cellulitis. 
Schroeder recognizes two forms of ovaritis, the follicular and the inter- 
stitial. Practically these divisions are of little importance, as they cannot 
be recognized during life. The disease may be either acute or chronic, the 
former tending to terminate in the latter. 
Symptoms.-There are no signs distinctly characteristic of ovaritis, or at 
least none which are not also present in peritonitis or pelvic cellulitis. Should 
there be pain and tenderness over the iliac region, greatly aggravated during 
menstruation, and should the ovary be found sensitive and enlarged when 
tested by the touch (which is made by a finger introduced into the rectum 
while with the other hand strong pressure is applied over the epigastrium, the 
body and limbs of the patient being well flexed), there is ground for supposing 
that inflammation of the ovary is present. When the left ovary is the one 
affected, pain is often experienced in defecation, from the pressure of the 
lower bowel against the sensitive organ. 
Treatment.-Even though there is some uncertainty in diagnosing inflam- 
mation of the ovaries, the treatment is the same as that which would be 
proper in those affections with which it may be readily confounded,-namely, 
* British Medical Journal, January 4, 1873, p. 18. 
f Ibid., January 3, 1874, p. 15. 
j Medical Record, vol. iv. p. 102, 1875. 
3 Medical Tinies and Gazette, March 11, 1865, p. 265. 
!' Medical Record, 1866, vol. ii., p. 36. 
Ibid., vol. ii. p. 380. OVARITIS. 
783 
rest in the recumbent position, the local abstraction of blood, hot hip-baths, 
and hot poultices laid over the iliac and hypogastric regions, together with 
vaginal douches of hot water. The bowels are to be kept in a soluble con 
dition; to allay pain, suppositories of opium should be introduced into the 
rectum; and to relieve restlessness, bromide of potassium, particularly at 
night, will be found useful. 
Sequels.-As an acute ovaritis is likely to become chronic, the ovaries are 
liable to suffer from various structural alterations, as atrophy, hypertrophy, 
displacement, abscess, and hemorrhage. 
Atrophy is both a physiological and a pathological condition, the former 
consequent on changes incident to the menopause, the latter the result of 
destructive inflammation. 
Hypertrophy is caused by inflammatory infiltration into the parenchymatous 
structure of the organs, and may be either temporary or permanent. When 
the result of acute inflammation, the products of the latter are less stable in 
their character and undergo retrograde changes, the enlargement subsiding 
by resolution. But when the disease has pursued a chronic course, the in- 
filtration becomes organized into connective tissue, which renders the hyper- 
trophy permanent. 
While it is true that in hypertrophy of the ovary the body is enlarged, 
it is generally at the expense of the follicular constituent, which, in con- 
sequence of the interstitial infiltration, is correspondingly diminished or 
atrophied. 
Inflammatory attacks of the ovaries, whether acute or chronic, are inim- 
ical to fertility; and hence females suffering from ovaritis or its results are 
often sterile. 
Symptoms.-The symptoms of hypertrophy are rational and physical. 
The former consist of a sense of weight or dragging in the iliac region, pain 
oi' distress during defecation, and dysmenorrhoea. The physical signs are 
those which are obtained by conjoined abdominal and rectal pressure, by 
which the size of the ovary, as well as any peculiarities of form or surface, 
can be determined. 
If these examinations are made both before and during menstruation, the 
enlargement will be found to increase materially when the catamenia are 
present. 
Treatment.-When there is a reasonable assurance that the diagnosis is 
correct, rest in the recumbent position during the menstrual periods must 
be strictly enforced ; as at that time the disease is likely to increase, from the 
determination of blood to the uterus and its appendages. Internally, the 
preparations of iodine are to be prescribed, as the tincture or the compound 
solution. Iodide of potassium is also recommended. Little benefit, however, 
is to be expected from these or from any other remedies. The hypertrophy 
may subside with the cessation of the menstrual function ; and at all events 
the disease will not be likely to endanger the life of the patient. Should the 
structural change in the ovary, along with the physical discomfort resulting 
from weight, adhesion, and displacement, develop a morbid condition of mind, 
as hysteroidal epilepsy or menstrual mania, the question of its removal must 
be taken into serious consideration. 
Abscess is among the most common terminations of ovaritis. The purulent 
accumulation fashions for itself a limiting wall or sac out of the connective 
tissue of the ovary; and very large collections of pus, amounting even to 
several pints, sometimes exist, destroying entirely the normal structure of 
the ovary and converting it into a large bag or sac. These abscesses exhibit 
a tendency to open into the bladder, examples of which have been furnished 
by West, Mosier, and others. 
Small abscesses may remain a long time in the ovary, and, there is reason 
to believe, are sometimes absorbed. When the accumulation of pus is large, 
the sac is likely to contract attachments to the abdominal walls, to the va- 
gina, and particularly to the rectum, and in one of these directions the con- 784 
SURGICAL DISEASES OF WOMEN. 
tents of the abscess usually find their way out of the body. Should the sac 
fail to become adherent, the pus is liable to be discharged into the peritoneum. 
Symptoms.-In addition to the other phenomena of inflammation, there are, 
in ovarian abscess, pain, fever, rigors, and probably a tumor bulging into the 
rectum or the vagina. These signs belong also to pelvic abscess: so that a 
doubt as to the correctness of a diagnosis must always exist in the mind 
of the practitioner. 
Treatment.-Hot hip-baths, hot vaginal douches of water or chamomile 
tea, and flaxseed-meal poultices applied over the hypogastric and iliac regions 
will favor the progress of suppuration. Pain must be controlled by enemata 
of laudanum or by opium suppositories; and as soon as the abscess has 
pointed, its contents should be removed by aspiration. 
Displacements.-Dislocations or displacements of the ovaries may follow 
from increased weight, due to inflammatory products; from preternatural re- 
laxation of the broad ligaments; from the pressure or crowding of the gravid 
uterus or of a pelvic tumor; and from the contraction of bands of lymph, 
the result of a previous peritonitis or cellulitis. These displacements are 
frequently congenital. The direction of the displacement is not always the 
same. That into Douglas's cul-de-sac is the most common, and is some- 
times accompanied by a retroversion of the uterus. Examples are recorded 
in which the ovary has entered one of the hernial passages: thus, in Cruveil- 
hier's case the ovary entered the inguinal canal and descended into the cor- 
responding labium; Kiwisch mentions a case in which the ovary occupied 
the foramen ovale; while Deneux, in his "Eecherches sur la Ilernie de 
1'Ovaire," alludes to others where these bodies followed the course of femoral 
and umbilical herniae, and, in rare instances, found their way into the thyroid 
foramen. 
An ovary which descends into Douglas's cul-de-sac may be discovered 
by an examination through the rectum. Not only will the body be found 
painful to the touch, but it may also be identified by the fact that it cannot 
be moved in a direction away from the side on which it belongs. 
When seated in hernial regions, the tumor might be very naturally con- 
founded with a portion of intestine or omentum. The periodical enlargement, 
tenderness, and pain which may be observed in the tumor during menstrua- 
tion, and the dragging uneasiness experienced in the iliac and hypogastric 
regions, together with the form of the swelling, in which the outlines of the 
ovary may be distinguished, will be important diagnostic features for con- 
sideration. 
Treatment.-If the displaced ovary is associated with retroversion of the 
uterus, the correction of the latter will be of the first importance, inasmuch as, 
if not followed by the spontaneous reduction of the dislocated ovary, it will 
lessen the uneasiness and pain experienced by the patient. If the ovary is 
found occupying the position of a hernia, and reducible, it should be replaced 
by taxis, and the protrusion prevented by guarding the rings with a properly- 
fitting truss. When its reduction is not feasible, which will most likely be 
the case, on account of adhesions, it will be necessary to defend the ovary 
against injury by a large concave pad attached to the spring of a truss. 
Neboux and Loeper have each operated successfully in a case of strangulated 
ovary by exposing the parts and dividing the obstruction by the knife. 
When the displacement is attended with a degree of suffering and disability, 
or when the tumor degenerates into an abscess or cyst, rendering surgical 
interference necessary, excision of the ovary will be required. The cases of 
Pott, Deneux, Meadows, and Lassus are in point as illustrating this plan 
of treatment. These gentlemen each removed successfully a displaced ovary 
which had become diseased. Similar operations have been done by Holmes 
and Gruersant, but, I believe, unsuccessfully. The modern operation of 
ovarectomy, which is working its way into professional favor, will no doubt 
be frequently resorted to in such cases in the future. OOPHORECTOMY, OR SPAYING. 
785 
Oophorectomy, or Spaying.-Battey's Operation. 
The operation of removal of the ovaries on account of extremely bad cases 
of dysmenorrhoea or for other morbid conditions resulting from vicious ovula- 
tion, though first performed by Professor Hegar, of Germany, on the 27th 
of July, 1872, and five days afterwards by Lawson Tait, must be regarded 
as having been formally introduced to the profession by Dr. Eobert Battey, 
of Eome, Georgia. 
There are two ways in which the ovaries may be removed, namely, through 
the abdomen and through the vagina. In either operation the antiseptic 
spray should be used and both ovaries always removed. 
Abdominal spaying.-In this operation the opening through the abdominal 
parietes is made in the median line between the umbilicus and the pubes, but 
nearer to the latter, and should not exceed two and a half or three inches in 
length. On dividing the peritoneum a vulsellum forceps is introduced into the 
pelvis, preceded by two fingers, which serve to guide the instrument to the 
ovary; the latter is seized and drawn sufficiently into the external wound 
to enable the operator to pass a double carbolized silk ligature through the 
broad ligament below the ovary, and to tic the included tissues on each side, 
cutting off both ends of the threads close to the knots after the ovary has 
been cut away above the ligatures. One being disposed of in this way, the 
other ovary is to be similarly treated, and the wound in the walls of the 
belly closed up by silver sutures, including the peritoneum. Over the line 
of approximation is next laid a pledget of antiseptic gauze, which in turn 
is covered with carbolized cotton-wool, and the whole supported by a broad 
flannel bandage enveloping the body. 
Sometimes, instead of using ligatures, the ovaries are crushed off close to 
their connection with the broad ligaments by the ecraseur. The ligature, 
however, more certainly secures the patient against hemorrhage. 
spaying.-In removing the ovaries through the vagina, the woman 
is placed in the lithotomy position, with the hips projecting over the lower 
edge of the table, and an assistant on either side supporting the limbs. A 
Sims speculum being introduced and the posterior wall of the canal retracted, 
the operator seizes the os uteri with a strong hook and drags it well down- 
ward and forward, after which an opening is made through the vagina pos- 
terior to the cervix uteri, either with a sharp-pointed bistoury or with the 
long scissors. If the latter are employed for this purpose, the puncture can 
be enlarged by pushing through it the closed blades of the scissors and then 
separating them. This done, the surgeon introduces a finger through the 
opening, along which he conducts a hook, and, catching with'its point the 
peritoneum at the bottom of Douglas's cul-de-sac, draws it through the in- 
cision in the vagina and divides it with the scissors. The cavity of the pelvis 
is now open, when the ovaries can be hooked down with the finger and vul- 
sellum, pulled through the wound thus made, ligated as in the abdominal 
operation, and cut away. 
The subsequent treatment is to be conducted precisely on the same princi- 
ples as after ovariotomy. 
The relative value of the two methods will depend on conditions which it 
is impossible to know antecedent to the performance of the operation. If 
the ovaries are perfectly free in the pelvis, the vaginal plan has the great 
advantage of making a wound in a locality which is admirably adapted for 
drainage; but, unfortunately, in many instances these bodies are bound to 
contiguous parts by inflammatory adhesions which refuse to yield, com- 
pelling the operator, as I have witnessed, to abandon the operation and 
adopt the abdominal section. Dr. Goodell determines the question of oper- 
ation by the mobility of the uterus, which he deems a good index to the state 
of the ovaries, believing that if the former admits of being easily pulled down, 
the latter are less likely to be bound by adventitious bands, and therefore are 
probably capable of being extirpated through the vagina, while if the reverse 
vol. ii.-50 786 
SURGICAL DISEASES OF WOMEN. 
is true and the womb refuses to be thus manipulated, the abdominal method 
is to be preferred. 
The harmless manner in which the peritoneum can be opened under the 
antiseptic spray certainly commends the abdominal as in most instances 
preferable to the vaginal plan of operating. 
Apart from the mode of operating, however, a very important question is 
to be considered, namely, the propriety of the procedure itself. This must 
be decided by three considerations: first, is the operation in itself attended 
with very great danger to life ? second, is the percentage of cures sufficiently 
great to warrant so radical a measure ? and, third, are the evils for which it 
is performed sufficiently grave to justify the woman in assuming the attendant 
risks ? 
In answer to the first interrogatory I will introduce a summary of cases of 
Battey's operation which has been made by Dr. Paul F. Munde in the "Amer- 
ican Journal of Obstetrics" for 1880, the aggregate numbei* being 120, of 
which number 28 died, a mortality of 22.6 per cent. The death-rate is not 
much above that which follows amputation of the thigh, and if the operation 
were done antiseptically, it would probably be very much reduced, so that, on 
the ground of fatality, the objections against its performance are not very 
forcible. 
In regard to the second consideration, although these figures are sufficient 
to establish the propriety of this operation so far as the question of mor- 
tality is concerned, they are not sufficient to enable us to promise, even in a 
majority of cases, an entire return to health. Statistics are defective as 
regards ultimate results. We are often left uninformed whether the word 
recovery means recovery from the operation or recovery from the disease. 
The sufferers to whom oophorectomy is proposed might well be pardoned if 
they should reply, in the words of the great master of dramatic art,- 
" Rather [would we] bear those ills we have, 
Than fly to others that we know not of." 
That dysmenorrhoea and its common attendant, ovaralgia, are cured when 
the ovaries are removed cannot be questioned; but as much cannot always 
be said of those cases of hysteroidal and maniacal insanity for which removal 
of the ovaries is practiced, though even in this unpromising field the opera- 
tion is not barren of good results, as I have reason to know from my own 
observation. 
The third consideration is based on the severity of the maladies for which 
the Battey operation is done. Is it sufficiently great to justify the risk 
already mentioned ? 
The arrival of the menopause puts an end to many of the functional dis- 
orders attending perverted ovulation, but not always to those which are 
organic. I think that in cases in which there are structural changes in the 
ovaries or the uterus constituting the exciting cause of persistent suffering 
and undermining the health physically and psychically, and for the relief 
of which all the usual remedies at command have been exhausted, there can 
be no good reason why the operation should not receive the unqualified sanc- 
tion of the profession. The adoption of such a test will limit this procedure 
to a few otherwise incurable cases, and will prevent an abuse of the operation, 
of which there is very great danger. 
The cases tabulated on the following pages, which have been collected for 
me from various sources by Dr. Baum, furnish some data which will be 
useful in estimating the proper status of oophorectomy; though it is to be 
regretted that in too many of the cases the result, with regard to cure as 
distinct from recovery following the operation, could not be obtained. OOPHORECTOMY, OR SPAYING. 
787 
Battey's Operation. 
00 
® 
00 
CtJ 
O 
Operator. 
Number of 
Cases of each 
Operator. 
Social Condition 
and Age. 
Indications for Operation. 
Nature of 
Operation. 
Ovaries re- 
moved. 
Condition 
of removed 
Ovaries. 
Result, and Source of 
Information. 
1 
Battey. 
1 
S. 30 
Amenorrhoea ; menstrual 
molimen; convulsions; 
repeated pelvic cellu- 
litis. 
Laparotomy. 
Both. 
Cure complete.* 
2 
<« 
2 
M. 32 
Persistent ovaralgia (left). 
Elytrotomy. 
One. 
Cystic degen- 
eration. 
Temporary relief; not im- 
proved.* 
3 
cc 
3 
M.38 
Continuous ovaralgia; en- 
dometritis ; threatened 
insanity. 
CC 
Both. 
Cure complete* 
4 
4 
M.24 
Ovaralgia aggravated by 
menses or exertion. 
ll 
One. 
Not entirely 
removed. 
Somewhat improved.* 
5 
ll 
5 
M. 35 
Ovaralgia; dysmenor- 
rhoea; coccyodynia. 
Constant ovarian pain and 
dysmenorrhoea ; threat- 
ened insanity. 
ll 
Ct 
Temporary relief; not im- 
proved.* 
6 
it 
6 
M. 30 
ll 
Both. 
Death.* 
7 
ll 
7 
S. 25 
Constant ovarian pain and 
dysmenorrhoea. 
ll 
Cure complete.* 
8 
ll 
8 
M. 28 
Constant ovarian pain ; ir- 
ritable uterus; metritis; 
pelvic cellulitis. 
ll 
cc 
Adhesions 
not entirely 
removed. 
Not improved* 
9 
ll 
9 
M. 35 
Second operation in Case 5. 
ll 
One. 
Not entirely 
removed. 
Not improved.* 
10 
ll 
10 
S. 29 
Constant ovarian pain; 
dysmenorrhoea. 
ll 
Both. 
Death* 
11 
ll 
11 
M. 22 
Atresia vaginae. 
Laparotomy. 
CC 
Cure complete.* 
12 
ll 
12 
M. 34 
Ovarian and pelvic pain ; 
dysmenorrhoea ; epilep- 
tic convulsions. 
Elytrotomy. 
cc 
Right, but 
not com- 
plete. 
Not improved.* 
13 
ll 
13 
M.28 
Hystero-epilepsy. 
Laparotomy. 
cc 
Good. Brit. Med. Journ., 
April3, 1880, p. 511.* 
14 
It 
14 
S. 22 
Hystero-epilepsy. 
Elytrotomy. 
cc 
Good. Brit. Med. Journ., 
April 3,1880, p. 511* 
15 
ll 
15 
M.37 
Violent menstruo-mania. 
c< 
cc 
Good. Brit. Med. Journ., 
April 3,1880, p. 511.* 
16 
Sims. 
1 
W. 35 
Dysmenorrhoea; menor- 
rhagia; retroflexed and 
hypertrophied uterus. 
Laparotomy. 
One. 
Cystic. 
Cure complete.* 
17 
ll 
2 
S. 40 
Intense and ever-recur- 
ring recto-enteralgia; 
diarrhoea; fissure, etc. 
ll 
CC 
CC 
Somewhat improved.* 
18 
ll 
3 
S. 35 
Dysmenorrhoea; ovarian 
and sacro-pelvic pain. 
Elytrotomy. 
cc 
Worse.* 
19 
ll 
4 
S. 20 
Dysmenorrhoea; ovarian 
and sacro-pelvic pain; 
anteflexion of uterus. 
ll 
cc 
Cystic. 
Worse.* 
20 
cc 
5 
M.38 
Retroversion of uterus; 
ovarian and sacro-pelvic 
pain. 
Laparotomy. 
Both. 
CC 
Death.* 
21 
ll 
6 
S. 20 
Dysmenorrhoea; coccy- 
odynia; sacro-lumbar 
and pelvic pain; photo- 
phobia ; retroflexion of 
uterus. 
Elytrotomy. 
One. 
Much worse.* 
• 
22 
ll 
7 
M. 38 
Dysmenorrhoea; ovarian 
and pelvic pain ; hyper- 
trophy of posterior wall 
of uterus, etc. 
CC 
Abandoned 
from being 
bound 
down by 
adhesions* 
23 
24 
25 
26 
27 
28 
Hegar. 
CC 
cc 
cc 
cc 
1 
2 
3 
4 
5 
6 
Ovaralgia. 
Uterine fibroids. 
Uterine fibroids. 
Uterine fibroids (used lat- 
eral incision directly 
over ovaries). 
Uterine fibroid. 
Perioophoritis; salpin- 
gitis ; perimetritis. 
Laparotomy. 
CC 
ll 
ll 
ll 
ll 
Both. 
CC 
cc 
ll 
cc 
cc 
One cystic, 
the other 
slightly 
changed. 
Death.* 
Greatly improved.* 
Greatly improved.* 
Greatly improved.* 
* 
Good.* 
29 
Thomas. 
1 
Ovaralgia; dysmenor- 
rhoea ; petit mal. 
Temporary insanity; dys- 
menorrhoea. 
Hemorrhage from uterine 
fibroids; intense dys- 
menorrhoea from ova- 
rian congestion. 
ll 
cc 
Cystic. 
Somewhat improved.* 
30 
31 
CC 
Trenholme. 
2 
1 
ll 
it 
One. 
Both. 
Enlarged. 
Death.* (Began to oper- 
ate per vaginam, but 
was compelled to open 
abdomen.) 
Cure complete.* 
* From Engelmann's table, American Journal of Obstetrics, vol. xi. p. 472. 788 
SURGICAL DISEASES OF WOMEN. 
Battey's Operation.-( Continued.) 
Cases. 
Operator. 
Number of 
Cases of each 
Operator. 
Social Condition 
and Age. 
Indications for Operation. 
Nature of 
Operation. 
1 Ovaries re- 
moved. 
Condition 
of removed 
Ovaries. 
Result, and Source of 
Information. 
32 
Trenholme. 
2 
Chronic ovaritis and ova- 
Elytrotomy. 
One. 
Not improved.* 
33 
Peaslee. 
1 
rian displacement. 
Absence of uterus; amen- 
orrhoea; hystero-epilep- 
Laparotomy. 
Both. 
Cystic. 
Death.* 
34 
Sabine. 
1 
sy ; pain in coitus. 
Ovaralgia; dysmenor- 
rhoea; inability to step 
with left leg. 
CC 
One. 
Normal. 
Greatly improved.* 
' 35 
Gilmore. 
1 
Atrophy of uterus; amen- 
orrhoea; cerebral con- 
gestion. 
Dysmenorrhoea and per- 
cc 
Both. 
Cured (?).* 
36 
Fallen. 
1 
cc 
CC 
Right, cystic; 
Death.* 
sistent ovaralgia. 
left, dislo- 
37 
Engelmann. 
1 
M.42 
Gastric and bronchial hys- 
tero-neurosis; metritis; 
retroflexion of uterus; 
cc 
cc 
cated. 
Slightly en- 
larged. 
Death (adhesions).* 
intense menstrual ex- 
acerbation. 
38 
cc 
2 
M.33 
Ovaralgia worse on slight- 
est exertion; dysmenor- 
rhoea; anteflexion 
cc 
cc 
Cystic. 
Death (adhesions).* 
and epileptiform at- 
tacks. 
39 
« 
3 
M. 31 
Ovaralgia; ovarian dys- 
menorrhcea; constant 
cc 
cc 
CC 
Death (firm adhesions).* 
pelvic pain and ante- 
flexion. 
40 
Koeberle. 
1 
Retroversion; constipa- 
cc 
One. 
Position of uterus good * 
tion; neurosis. 
41 
Kaltenbach. 
1 
Uterine tumor. 
cc 
Death.* 
42 
Frew. 
1 
Obstructive dysmenor- 
rhoea with hysteria. 
cc 
Both. 
Greatly improved. N. Y. 
Med. Record, vol. xiv. 
43 
Prince. 
1 
S. 18 
Hystero-epilepsy; mind 
Elytrotomy. 
CC 
p. 8, 1878. 
Death. N. Y. Med. Rec., 
44 
Smith. 
1 
M.40 
wavering. 
Ovarian dysmenorrhoea. 
Laparotomy. 
cc 
Right, atro- 
phy ; left, 
vol. xv. p. 106, 1879. 
Cured. Brit. Med. Journ., 
July 12, 1879, p. 41. 
cystic, and 
atrophy. 
45 
Schucking. 
1 
M.38 
Marked hysteria; epi- 
CC 
cc 
Cured. From London Med. 
lepsy; metrorrhagia; 
dysmenorrhoea and tris- 
Record; Amer. Journ. 
Med. Sciences, January, 
mus. 
1880, p. 286. 
46 
Schroeder. 
1 
Insane girl with nympho- 
cc 
cc 
Normal. 
Cured. American Journ. 
mania. 
Obstet., Jan. 1880, p. 194.f 
47 
CC 
2 
Large myoma. 
Improved; grew again. 
Amer. Journ. Obstet., 
48 
Langenbeck. 
1 
Absence of vagina; men- 
ses and coitus through 
bladder. 
Laparotomy. 
Both. 
January, 1880, p. 194.f 
Cured. Amer. Journ. Ob- 
stet., January, 1880, p. 
194.f 
49 
Martin. 
1 
Violent ovaralgia, with 
scarce menses. 
Cured completely. Amer. 
Journ. Obstet., Jan. 
1880, p. 194.f 
50 
CC 
2 
Violent ovaralgia, with 
scarce menses. 
Cured completely. Amer. 
Journ. Obstet., January, 
1880, p. 194.f 
51 
cc 
3 
Uterus imperfectly devel- 
Laparotomy. 
Both. 
Cure. Amer. Journ. Ob- 
52 
Mtiller. 
1 
oped (both ovaries on 
left side). 
Ovarian neuralgia. 
stet., January, 1880, p. 
194.f 
Cure. Amer. Journ. Ob- 
stet., Jan. 1880, p. 194.f 
53 
Czerny. 
1 
Hysteria and enlarged 
Both. 
No cure. Amer. Journ. 
54 
Lusk. 
1 
S. 39 
ovaries. 
Dysmenorrhoea. 
Laparotomy. 
CC 
Enlarged 
and cystic. 
Obstet., January, 1880, 
p. 194,f 
Death recorded in Amer. 
Journ. Obstet., July, 
1880, p. 599. 
55 
Malins. 
1 
M.33 
Pains and irregular men- 
ses. 
CC 
cc 
Normal. 
Greatly improved. British 
Med. Journ., May 22, 
1880, p. 772. 
56 
CC 
2 
M.36 
Pain and prostration, es- 
pecially at menses, also 
in defecation. 
cc 
cc 
CC 
Greatly improved; sexual 
desire not impaired; 
menstruates regularly. 
Brit. Med. Journ., May 
22, 1880, p. 772. 
57 
Freund. 
1 
Fibro-myoma. 
cc 
Death. British Med. 
Journ., May 24, 1879, p. 
763; A. R. Simpson's 
table. 
f Private communication. 
* From Engelmann's table, Amer. Journ. of Obstet., vol. xi. p. 472. OOPHORECTOMY, OR SPAYING. 
789 
Battey's Operation.-( Continued.) 
X 
® 
3 
O 
Operator. 
Number of 
Cases of each 
Operator. 
Social Condition 
and Age. 
Indications for Operation. 
Nature of 
Operation. 
Ovaries re- 
moved. 
Condition 
of removed 
Ovaries. 
Kesult, and Source of 
Information. 
58 
59 
Tauffer. 
A. R. Simpson. 
1 
1 
M.36 
Dysmenorrhoea. 
cc 
Laparotomy. 
CC 
Both. 
CC 
Cure. British Med. Jour., 
May 24, 1879, p. 763. A. 
R. Simpson's table. 
Good. British Med. Jour., 
Mav 24,1879, p. 763. A. 
60 
McGuire. 
1 
Ovaritis. 
cc 
K. Simpson's table. 
Recovered. Amer. Journ. 
Obstet., Jan. 1880, p. 194.* 
61 
Il 
2 
CC 
cc 
Recovered. Amer. Journ. 
Obstet., Jan. 1880, p. 194.* 
62 
Freud. 
2 
Myomata. 
Laparotomy. 
cc 
Menopause followed. 
Amer. Journ. Obstet., 
Jan. 1880, p. 194* 
63 
li 
3 
CC 
CC 
cc 
Menopause followed. 
Amer. Journ. Obstet., 
Jan. 1880, p. 194* 
64 
li 
4 
Hystero-epilepsy. 
cc 
cc 
Menopause followed. 
Amer. Journ. Obstet., 
Jan. 1880, p. 194.* 
65 
66 
Goodell. 
cc 
1 
2 
S. 33 
M. 
Uterine fibroids; ovaral- 
gia; dysmenorrhoea; 
fear of insanity. 
Pernicious menstruation. 
Elytrotomy. 
Laparotomy. 
cc 
cc 
Healthy. 
CC 
Cure complete. 
Vaginal incision failed 
and abandoned; abdom- 
inal resorted to; died* 
67 
CC 
3 
M. 
Ovaralgia; pernicious 
menstruation. 
Elytrotomy. 
cc 
Inflamed. 
Died.* 
68 
ll 
4 
Hysteroidal insanity. 
CC 
cc 
Recovered; improved; 
three years under ob- 
servation.* 
69 
ll 
s. 
CC cc 
cc 
cc 
Enlarged. 
Recovered; cured; three 
months under observa- 
tion.* 
70 
li 
6 
s. 
Ovaralgia; threatened in- 
sanity. 
Laparotomy. 
cc 
Healthy. 
Recovered; much im- 
proved ; six months un- 
der notice; vaginal in- 
cision failed; abandoned, 
and abdominal opera- 
tion resorted to.* 
71 
Cl 
7 
s. 
Ovaritis; ovaralgia. 
Elytrotomy. 
cc 
Enlarged 
and indu- 
Recovered; much im- 
proved ; five months uu- 
rated. 
der notice.* 
72 
li 
8 
s. 
Ovaritis; menorrhagia. 
CC 
cc 
Healthy. 
Recovered; cured; three 
years underobservation.* 
73 
74 
Cl 
Savage. 
9 
1 
s. 
S.31 
Ovaritis; ovaralgia. 
Ovarian and menstrual 
pain; chronic metritis; 
enlargedand retroflexed 
uterus; menorrhagia. 
"Somewhat similar to 
cc 
Laparotomy. 
cc 
cc 
Softened. 
Kight, adhe- 
after left; 
opause fol- 
Died.* 
rent; removed one year 
less pain; improved; men- 
lowed.f 
75 
cc 
2 
CC 
cc 
cc 
Improved; life made bear- 
above, but no chronic 
able; menopause.f 
metritis." 
76 
77 
ii 
ii 
3 
4 
S. 18 
M. 28 
No vagina or vaginal ap- 
erture; rudimentary ute- 
rus ; monthly molimen, 
with pelvic pain and in- 
tense pain in head. 
Dysmenorrhoea; dyspa- 
reunia and dysuria. 
cc 
cc 
cc 
cc 
Both cystic. 
Left, shriv- 
eled; right, 
normal 
Result not stated; had 
never menstruated.f 
Adhesions; improved; 
not so much pain; not 
complete removal of 
size; cal- 
right ovary.f 
careous 
pieces re- 
moved. 
78 
Tait. 
1 
Hemorrhage from myoma. 
cc 
cc 
Death. British Med. 
Journ., May 3, 1879, p. 
813. 
79 
CC 
2 
CC cc cc 
cc 
cc 
Death. British Med. 
Journ., May 3, 1879, p. 
813. 
80 
cc 
3 
cc cc cc 
cc 
cc 
Death. British Med. 
Journ., May 3,1879, p. 
813. 
81 
cc 
4 
S. 26 
Dysmenorrhoea. 
cc 
cc 
Under observation one 
year; complete relief. 
British Med. Journ., 
82 
cc 
5 
CC 
CC 
cc 
cc 
July 10,1880, p. 48. 
Under observation six 
months; complete re- 
lief. Brit. Med. Journ., 
July 10,1880, p. 48. 
* Private communication. 
f Obstetrical Journal of Great Britain and Ireland, May 31,1880, p. 258. 790 
SURGICAL DISEASES OF WOMEN. 
Battey's Operation.-( Continued.') 
DO 
® 
DO 
CG 
o 
Operator. 
Number of 
Cases of each 
Operator. 
Social Condition 
and Age. 
Indications for Operation. 
Nature of 
Operation. 
Ovaries re- 
moved. 
Condition 
of removed 
Ovaries. 
Result, and Source of 
Information. 
83 
Tait. 
6 
S. 34 
Dysmenorrhoea. 
Laparotomy. 
Both. 
Under observation one 
year; great relief; pro- 
gressing satisfactorily. 
Brit. Med. Journ., July 
10, 1880, p. 48. 
84 
cc 
7 
M.43 
Menstrual epilepsy and 
mania. 
cc 
Compl etearrest of epilepsy 
and mania slowly disap- 
pearing ; underobserva- 
tion eleven months. 
Brit. Med. Journ., July 
10,1880, p. 48. 
85 
It 
8 
S. 28 
Dysmenorrhoea. 
ll 
CC 
Under observation eight 
months; complete re- 
lief. Brit. Med. Journ., 
July 10,1880, p. 48. 
86 
ll 
9 
S.24 
CC 
cc 
cc 
Under observation eight 
months; great relief; 
progress satisfactory. 
Brit. Med. Journ., July 
10,1880, p. 48. 
87 
ll 
10 
S. 21 
cc 
CC 
cc 
Under observation seven 
months; complete re- 
lief. Brit. Med. Journ., 
July 10, 1880, p. 48. 
88 
ll 
11 
M. 29 
It 
CC 
cc 
Under observation six 
months; complete re- 
lief. Brit. Med. Journ., 
July 10,1880, p. 48. 
89 
u 
12 
M. 22 
Ct 
cc 
cc 
Under observation four 
months; complete re- 
lief. Brit. Med. Journ., 
July 10, 1880, p. 48. 
90 
It 
13 
M.34 
Cl 
ll 
cc 
Under observation four 
months; great relief; 
progress satisfactory. 
Brit. Med. Journ., July 
10,1880, p. 48. 
91 
u 
14 
M. 37 
Cl 
ll 
cc 
Under observation three 
months; relief imme- 
diate and complete. Brit. 
Med. Journ., July 10, 
1880, p. 48. 
92 
It 
15 
S. 17 
Menstrual epilepsy and 
mania. 
cc 
cc 
Under observation three 
months; great relief. 
Brit. Med. Journ., July 
10, 1880, p. 48. 
93 
it 
16 
M. 23 
* 
Dysmenorrhoea. 
It 
Under observation two 
months; relief imme- 
diate and complete. Brit. 
Med. Journ., July 10, 
1880, p. 48. 
Under observation ten 
months; complete ar- 
rest. Brit. Med. Journ., 
July 10, 1880, p. 48. 
94 
It 
17 
S. 21 
Menorrhagia. Cause un- 
known. 
cc 
cc 
95 
ll 
18 
W. 47 
Hemorrhage from myoma. 
cc 
cc 
Under observation eight 
months; complete ar- 
rest. Brit. Med. Journ., 
July 10,1880, p. 48. 
96 
Ci 
19 
W. 52 
tc cc cc 
cc 
cc 
Under observation seven 
months; complete ar- 
rest. Brit. Med. Journ., 
July 10, 1880, p. 48. 
97 
tc 
20 
M.34 
cc cc cc 
<C 
cc 
Under observation five 
months; complete ar- 
rest. Brit. Med. Journ., 
July 10, 1880, p. 48. 
No hemorrhage for three 
months, and then lost 
sight of. Brit. Med. 
Journ., July 10, 1880, p. 
48. 
98 
Ct 
21 
S. 48 
cc cc Cl 
cc 
cc 
99 
tc 
22 
S. 36 
Menorrhagia from hyper- 
trophied ovaries. 
cc 
cc 
Under observation four 
months; complete ar- 
rest. Brit. Med. Journ., 
July 10, 1880, p. 48. 
100 
ll 
23 
S. 52 
Hemorrhage from myoma. 
<c 
cc 
Under observation three 
months; complete ar- 
rest. Brit. Med. Journ., 
July 10,1880, p. 48. OOPHORECTOMY, OR SPAYING. 
791 
Battey's Operation.-( Continued.} 
CD 
S 
3 
Q 
Operator. 
Number of 
Cases of each 
Operator. 
Social Condition 
and Age. 
Indications for Operation. 
Nature of 
Operation. 
Ovaries re- 
moved. 
Condition 
of removed 
Ovaries. 
Result, and Source of 
Information. 
101 
Tait. 
24 
S. 42 
Hemorrhage from myoma. 
Laparotomy. 
Both. 
Under observation two 
months; complete ar- 
rest. Brit. Med. Journ., 
July 10, 1880, p. 48. 
102 
<c 
25 
M.33 
« ll ll 
<< 
cc 
Under observation two 
months; complete ar- 
rest. Brit. Med. Journ., 
July 10,1880. p. 48. 
103 
<c 
26 
S. 38 
ll ll ll 
ll 
ll 
Death. Brit. Med. Journ., 
July 10,1880, p. 48. 
104 
ll 
27 
S. 46 
ll It li 
ll 
ll 
Under observation two 
months; complete ar- 
rest. Brit. Med. Journ., 
July 10,1880, p. 48. 
105 
u 
28 
M.39 
ll ll ll 
ll 
ll 
Under observation two 
months; complete ar- 
rest. Brit. Med. Journ., 
July 10,1880, p. 48. 
106 
u 
29 
M. 38 
Abscess of ovary. 
ll 
ll 
Complete arrest. Brit. 
Med. Journ., July 10, 
1880, p. 48. 
107 
ll 
30 
M.46 
Hemorrhage from myoma. 
ll 
One, 
and 
other 
partly 
Death. Brit. Med. Journ., 
July 10, 1880, p. 48. 
Of 107 cases in which the indications for operating have been stated, after deduct- 
ing 10 cases where only one ovary was extirpated, one of which died, 6 cases of 
uncompleted operation, all recovering, 2 cases in which the result is not stated, and 
1 accidental removal, there remain 88 cases of completed double operation, of which 
67 recovered and 21 died, or 23.86 per cent. 
General Summary of all Cases of Oophorectomy, or Battey's Operation, included in the 
Preceding Table. 
Operator. 
Total 
Cases. 
Laparotomy. 
Elytrotomy. 
References. 
Recov- 
ered. 
Died. 
Recov- 
ered. 
Died. 
Hegar 
42 
35 
7 
TTeo-nr's table. Lon. Med. "Record. March 15.1880. l). 85. 
Schroeder 
2 
2 
cc 
' ll ll ' 
ll 
4. 
Freud 
4 
3 
1 
cc 
ll ll 
ll 
Tian gen beck 
1 
1 
ll 
ll ll 
ll 
" 1 
Marti n 
3 
3 
ll 
ll ll 
ll 
cc 
Mill ler 
3 
3 
ll 
ll ll 
ll 
ll 
Czerny 
3 
2 
1 
ll 
ll ll 
ll 
ll 
Sch licking 
1 
1 
cc 
ll ll 
ll 
ll 
"Battey 
15 
3 
10 
2 
12 cases, 
Trans. Amer. Gyn. Soc., vol.i. 
April 3,1880, p. 511. 
able. 
communication. 
3 cases, 
Brit. Med. 
Trenholme 
2 
1 
1 
Journ". 
Hegar's 
Personal 
Goodell 
9 
1 
1 
5 
2 
10 
5 
1 
4 
Engelmann 
3 
3 
it 
CC 
Thomas 
2 
1 
1 
ll 
ll 
Pea.slee 
1 
1 
ll 
ll 
Sabine 
1 
1 
ll 
ll 
Von Nussbaum 
Tauffer 
1 
1 
ll 
1 
1 
ll 
ll 
Netzel 
1 
1 
ll 
ll 
Peinice ••••••••• 
2 
2 
ll 
ll 
Alberts ... 
1 
1 
ll 
ll 
T. Spencer Wells... 
A P. Simpson 
1 
1 
ll 
ll 
1 
1 
ll 
It 
Kaltenbach ••••••••• 
1 
1 
ll 
ll 
Gilmore 
1 
1 
ll 
ll 
Martin 
2 
2 
ll 
ll 
Fallen ••■•••••••••••••• 
1 
1 
Ct 
ll 
Koeberle.. ............ 
1 
1 
ll 
ll 
Frew 
1 
1 
ll 
ll 
Prince 
1 
1 
ll 
ll 
Wolponer •••••••••••• 
1 
i 
ll 
cc 
Esmarch 
1 
i 
ll 
ll 792 
SURGICAL DISEASES OF WOMEN. 
General Summary.-{Continued.) 
Operator. 
Total 
Cases. 
Laparotomy. 
Elytrotomy. 
References. 
Recov- 
ered. 
Died. 
Recov- 
ered. 
Died. 
Tait 
30 
1 
10 
2 
2 
1 
1 
4 
25 
5 
Brit. Med. Journ., May 31,1879. p. 813, 3 cases. 
Brit. Med. Journ., July 10,1880, p. 48,27 cases 
Hegar's table. 
4C M 
<« cc 
Brit. Med. Journ., May 22,1880, p. 772. 
" " July 12, 1879, p. 41. 
Amer. Journ. Obstet., July, 1880, p. 599. 
Obstet. Journ. Great Britain and Ireland, 
May 31,1880, p. 258. 
West 
1 
Noeggerath 
8 
2 
2 
1 
2 
McGuire 
Malins 
Heywood Smith,... 
Lusk 
1 
Savage 
4 
Total 
171 
117 
27 
22 
5 
Formulating the material of the above table, there were 171 cases, of 
which 139 recovered and 32 died, or 18.72 per cent. 
Of the 171 cases, there were 144 by laparotomy, of which 117 recovered 
and 27 died, or 18.75 per cent.; and 27 by elytrotomy, with 22 recoveries and 
5 deaths, or 18.51 per cent. 
Up to September, 1879, Hegar* had performed 42 operations, all by lapa- 
rotomy. Of these 35 recovered and 7 died, or 16.64 per cent. He has 
arranged these cases into groups. 
The first group consisted of 13 cases, with distinct, small tumors, either 
bilateral or unilateral. Here it is difficult to draw the dividing-line between 
ordinary ovariotomy and oophorectomy. Both ovaries were removed in all 
the cases, and the tumors were about the size of a billiard-ball. The affec- 
tions were exceedingly diverse, as ordinary follicular or papillary cystomata, 
dermoid, parovarian, and so-called tubo-ovarian cysts, etc. Extensive peri- 
tonitis and adhesions were present. Death occurred in 2 cases; all symptoms 
disappeared in 8, and 3 had subsequent abdominal pains. 
The second group, of 12 cases, comprises fibroids. The tumors were not 
very large. The operation is of doubtful propriety when large fibroids are 
present. Death occurred in 3 cases from septic peritonitis. In 6 cases com- 
plete menopause and shrinking of the tumor occurred; in 2 cases, of three 
or four months' standing, menopause continued; 1 case, with large tumor, 
was relieved. The tumor, however, recurred, followed by hemorrhage, and 
death in eleven months. 
The third group embraced 5 cases of chronic oophoritis. One died, and 3 
were relieved from all trouble, even after extended observation. 
The fourth group was made up of 5 cases, chiefly of uterine affections, such 
as incorrigible retroflexions, sharp anteflexions, and hyperplasia. Death fol- 
lowed in 1 case from ileus; menopause, with relief, occurred in 2; and 2 were 
too recent to form a prognosis. 
The fifth group contained 7 cases, with decided chronic inflammation of 
recurrent character, perioophoritis, salpingitis, perimetritis, and parametritis, 
with adhesions, and neuroses, culminating in insupportable suffering. None 
fatal. In 3 menopause and complete cure followed; in 1 menopause, and 
much improvement; in 1 regular typical hemorrhage accompanying im- 
provement. Two cases were too recent to justify any prognosis. 
Results.-After deducting fatal and too recent cases, there remain 28, of 
which number 21 are perfect results; in 1 there was transient success; in 3 
pains continued after extirpating small ovarian tumors; and in 3 there was 
considerable improvement. 
Influence upon menstruation.-After deducting the fatal cases, those which 
were too recent, and those in regard to which no information was received, 
* American Journal of Obstetrics, January, 1880, p. 194. TUMORS OF THE OVARIES. 
793 
there remain 30 cases. Of these, the menopause was complete in 26; in 3 
there were irregular hemorrhages; and in 1 there was typical hemorrhage. 
" Of 132 cases of extirpation of both ovaries during menstrual life, there 
were 15 which had, so far as I can learn, regular monthly fluxes, and 9 in 
which such fluxes were either irregular or lessened in amount."* 
He thinks that all such cases have been deemed worthy of note, and that 
not all cases of double ovariotomy have been published. Koeberle asserts 
that the menstrual flux never returns unless a portion of the ovarian stroma 
has been left behind, and that this may occur whenever the pedicle is short 
and the clamp is used. All his cases had " amenorrhcea." 
Tumors of the Ovaries. Cystomata. 
Tumors of the ovaries may be classified as benign and malignant. They 
are also divided into liquid, solid, and mixed. 
Liquid or cystic tumors are parasitic, follicular, parenchymatous, or re- 
trogressive or liquefying. 
Parasitic cysts are such as are formed around a species of the echinococcus, 
and are so rare that our information on the subject is very imperfect. 
Follicular cysts are often described as dropsy of the Graafian follicles. 
They are sometimes single, affecting a single follicle, and at other times nu- 
merous, implicating a large portion of the follicles of the ovary. 
These cysts are probably developed from an increase of the normal fluid 
contents of the follicle, the latter, from some cause, refusing to rupture. 
They answer to the so-called retention cysts; or, after the rupture of a fol- 
licle the opening may, according to Rokitansky, again close, and a cyst be 
formed between the wall of the Graafian body and the corpus luteum. In- 
terstitial cysts also form in the connective tissue of the ovary independent 
of the Graafian follicles, and having for a wall the tunica albuginea of the 
ovary. 
Waldeyer regards all cystic tumors as epithelial, or originating in the 
glandular component of the ovary, and possessing in themselves the charac- 
teristics of both mucous membrane and skin. As it is not contemplated to 
enter into any detailed description of the different views entertained by 
writers with regard to the pathology of ovarian tumors, I shall simply adopt 
that division of the subject which is commonly recognized, and which answers 
for the practical end in view. 
Varieties.-Ovarian cysts appear as simple and compound tumors, or uni- 
locular and multilocular. 
Unilocular.-The simple unilocular or monocystic cyst consists of a single 
sac formed of the tunica albuginea of the ovary. The unilocular tumor is 
thought by some to be multilocular in its early stage of formation, the walls 
in that stage either melting down by absorption or disappearing by rupture. 
The cyst-wall differs in thickness in different tumors, being sometimes quite 
thin, but oftener thick from interstitial additions to its structure. 
Compound or multilocular cysts are those from the walls of which other 
cysts arise, developed from lhe inner surface of the first (endogenous), or as 
outgrowths from the original wall (exogenous), or, finally, as the simul- 
taneous development of a number of cysts, each formed from a Graafian follicle. 
(Figs. 1503, 1504.) In the compound or multilocular variety the different 
cysts may communicate with one another by the breaking down, absorption, 
or rupture of their contiguous walls, or they may remain as independent and 
distinct compartments. (Fig. 1505.) 
Contents.-The contents of ovarian cysts differ in color, in consistence, and 
in quantity. The color may be brown, resembling that of soft soap, dark 
yellow, or, when the cyst contains blood, reddish brown. 
In consistence the contained material is sometimes thin, sometimes ropy, 
and frequently gelatinous, and so dense that it refuses to escape, even through 
* Goodell's Lessons in Gynaecology, 1879, p. 285. 794 
SURGICAL DISEASES OF WOMEN. 
the largest canula. In addition to the liquid contents, ovarian cysts often 
contain myxomatous, papillomatous, hydatid, and adenoid formations. Those 
Fig. 1504. 
Fig. 1503. 
Endogenous multilocular cyst containing secondary and 
tertiary cysts. 
Interior of a multilocular cyst: A A, lining 
membrane; BBB, groups of secondary cysts; 
CCC, secondary cysts the walls of which have 
given way and are being absorbed. 
belonging to the dermoid class may contain foetal remains, as bone, cartilage, 
hair, teeth, etc. When a papilloma exists, formed by a proliferation of the 
connective tissue of the tumor, blood 
is often found in the sac, derived from 
the frail vessels of the growths, which 
have given way. 
Multilocular cysts, as a rule, are 
more likely to be filled with thick con- 
tents than the unilocular ones. 
These growths attain in many in- 
stances enormous dimensions, and con- 
tain not unfrequently from six to eight 
gallons of fluid. If the theory is cor- 
rect that these cysts are developed 
from the glandular parenchyma of the 
ovary, their contents must be largely 
derived from a degeneration or lique- 
faction of the cells within. 
The ovaries are not equally liable 
to cystic disease, the right being 
more frequently attacked than the 
left. In an aggregate of 680 cases, 
346 w'ere on the right and 252 on 
the left side. Both ovaries may be 
affected at the same time, the pro- 
portion of double tumors being about 6 per cent. 
Causes.-Among the causes which have been thought to explain the de- 
velopment of ovarian tumors, age is the most notable. In an analysis of 
1123 cases of ovariotomy, the largest number in any decade between fifteen 
and seventy-315-occurred between the ages of twenty-five and thirty-five. 
The period of life at which the function of ovulation is most active is that 
Fig. 1505. 
Multilocular cyst, loculi distinct. TUMORS OF THE OVARIES. 
795 
between twenty-five and forty-five. Examples of the disease, however, are 
sometimes witnessed both in infancy and in old age. Married women are 
more frequently the subjects of ovarian dropsy than women who are single. 
In 1123 ovariotomies collected from various sources, 679 of the patients were 
married and 444 single. 
Symptoms.-The general signs of an ovarian tumor are enlargement of 
the abdomen, a dragging weight in one or other of the iliac regions, perhaps 
vesical or rectal irritation, and gradual loss of flesh. As these symptoms 
are common to other abdominal tumors, they are valueless when considered 
by themselves. 
Diagnosis.-The recognition of an ovarian tumor must be effected by a 
physical examination. 
To conduct this properly, the woman should be placed on her back, the ab- 
domen uncovered, and, that the parietes of the latter shall be sufficiently 
relaxed, the knees must be drawn up. Deep pressure being made in the 
iliac and hypogastric regions, it will not be difficult to detect a tumor if one 
exists. But there are many tumors other than ovarian which occur within 
the compass of these regions, and with which the variety under considera- 
tion may be confounded, among which may be named the fibro-cysts and 
the fibro-myomata of the uterus, cysts of the broad ligament, ascites, preg- 
nancy, renal cysts, phantom swellings, carcinoma, fecal accumulations, etc. 
I shall confine myself to a few salient diagnostic characteristics. 
If the tumor has not risen from the pelvis and there have been symp- 
toms attracting the attention of the patient, a bimanual examination should 
be made, with the object of determining the origin of the growth, whether 
uterine or ovarian. With the body and limbs flexed, and by means of simul- 
taneous pressure made through the vagina and over the hypogastrium, it is 
possible to ascertain whether the tumor is central or lateral, and, if the latter, 
even to feel the notch or interspace between the uterus and the ovary. 
By the same manipulation the independent mobility of the two may be 
established if the disease is ovarian. Again, if a sound is introduced into 
the uterus and it remains motionless while the tumor in question is pressed 
from side to side, there is an additional reason for believing it to be ovarian 
and distinct from the womb. 
In the case of pedunculated subperitoneal fibromata, the differentiation 
would necessarily be more difficult, as the tumor, especially when the pedicle 
is long, could be carried to one side without disturbing the stability of the 
uterus. In cases of this kind, unless the disease is cystic, the enlargement 
would feel much more dense than is common in ovarian cysts. 
Again, uterine fibroids are often multiple, and if, on examination through 
the rectum, vagina, or abdominal parietes, other nodules could be discovered, 
they would be confirmatory of the uterine origin of the disease. 
Fibro-cystic growths of the uterus and of its appendages present many symp- 
toms in common with ovarian tumors. But there is one notable difference, 
which has been properly insisted upon by Atlee, namely, the spontaneous 
coagulation of the fluid drawn from the former when exposed to the air. 
This does not occur in that derived from an ovarian cyst. The microscopic 
appearances of the fluid of fibro-cystic tumors are also claimed to be sig- 
nificant : it is said to contain a few spindle-shaped or fibre cells in addition 
to large epithelial ones. (Fig. 1506.) This fibre cell is said to belong to no 
other abdominal dropsical fluid. 
Uterine tumors are more generally attended by disturbances of the men- 
strual function than are those connected with the ovaries. In the former 
menorrhagia is quite common; not so in the latter. In the former, also, 
we frequently find the cavity of the uterus increased in depth, but not so in 
ovarian disease. Emaciation is a characteristic of ovarian, but not of uterine 
growths. 
Even when it has been settled that the tumor is in the ovarian region, there 
still remains the doubt whether it may not be seated in the broad ligament, 796 
SURGICAL DISEASES OF WOMEN. 
and not in the ovary,-a cyst, for example, similar to that represented in 
Fig. 1507. 
The late Dr. Atlee pointed out in this connection a very important diag 
Fig. 1506. 
Fig. 1507. 
Fibre or spindle cells, also epithelial cells, found in 
fibro-cystic tumors of the uterus. 
Cyst of the broad ligament mistaken for an ovarian 
tumor. 
nostic sign, viz., that the fluid which is contained in the cyst of a broad liga- 
ment differs widely from that of an ovarian sac. It is thin, clear, colorless as 
water, and of a specific gravity not exceeding 1009; it is not coagulated by 
either heat or nitric acid. Chemically it is rich in chloride of sodium. These 
characteristics are foreign to ovarian fluids, which are opaque, viscid, and 
rich in fibrin. 
When the ovarian cyst rises from the pelvis into the abdomen, the ques- 
tion of ascites and pregancy will naturally come up in the consideration of 
the case. 
Between ascites and ovarian dropsy there are certain differences not diffi- 
cult to detect. In ascites the fluid is diffused, the dullness on percussion 
general, and the distention of the abdominal walls quite uniform in all direc- 
tions ; while in ovarian dropsy the fluid is more circumscribed, the percussion 
sounds being resonant or clear in certain regions exterior to the sac, as the 
iliac and lumbar, when the patient is placed on one or the other side. Neither 
do the flanks bulge as in ascites. An examination in ascites generally reveals 
some cardiac, hepatic, or renal disease, which is not usual in cases of ovarian 
tumor. Again, in ascites the fluid is thin and straw-colored. In ovarian 
disease it is thick, syrup-like, or gelatinous, and generally very much darker 
in color. 
Both ascites and ovarian cysts are often found in the same patient; but 
even then the walls of the latter may be discovered by palpation. 
From colloid, encephaloid, and papillomatous tumors it is often impossible to 
distinguish ovarian cysts, especially of the multilocular variety, without 
making an exploratory opening. Generally in the former affections there 
is more local suffering or pain, with greater implication of the general health, 
and the marks of a cachexia are more strongly impressed on the face than 
in ovarian disease. 
Ovarian cysts may have outgrowths of connective tissue highly vascular, 
projecting into the interior of the sac or situated upon its peritoneal surface, 
thus blending with the ovarian a papillary element. When the contents of 
an ovarian tumor exhibit the presence of much blood, the existence of such a 
growth may be strongly suspected. 
In forming a diagnosis, therefore, in cases of abdominal tumors containing 
fluids, tapping should not be neglected. 
It would seem impossible to confound the gravid uterus with an ovarian TUMORS OF THE OVARIES. 
797 
tumor, but the mistake has been made. The suspension of the catamenia, 
the continuity of the cervix uteri with the abdominal enlargement, the two 
moving together, the enlargement of the mammas, and the sounds of the 
foetal heart, which distinguish pregnancy, ought to be sufficient to prevent 
such an error from being committed. 
Hydronephrosis and renal cysts in many instances give rise to such altera- 
tions in the urine as will aid in differentiating enlargements. (See Hydrone- 
phrosis.} 
Diagnostic tapping.-Dr. Drysdale, of Philadelphia, who has examined a 
large number of abdominal fluids, asserts positively the existence of a dis- 
tinct specific ovarian cell, which he says can always be recognized. This 
statement, if correct, must be regarded as of the utmost importance in im- 
parting certainty to the diagnosis. This cell is described as an albuminoid 
body, oval in form, and having a granular appearance under the microscope, 
without a nucleus, and usually about the size of a pus-corpuscle. As granular 
cells are present in other abdominal fluids besides those contained in ovarian 
tumors, Dr. Drysdale relies on acetic acid and ether as differentiating tests. 
When the first agent is added to the fluid within the field of observation, the 
cell, if ovarian, will remain almost entirely unchanged, the granules possibly 
becoming a trifle more distinct, but no nuclei appearing as in pus cells; while 
the addition of ether causes the granules to become somewhat more trans- 
parent. Fig. 1508, taken from Dr. Drysdale's pamphlet on the subject, ex- 
hibits a number of microscopic forms usually present in ovarian fluids. 
Fig. 1508. 
A, Epithelial cells of different forms; B, oil-globules; C, granular matter; D, crystals of cholesterin ; E, ovarian 
cell; F, blood-corpuscles; G, pus-corpuscles; JI, pus-corpuscles treated by acetic acid; I, exudation-corpuscles in 
leucocytes. 
Many very competent microscopists, however, deny the existence of any 
distinctive ovarian cell; so that the subject may be regarded as still sub judice. 
Excluding altogether from the examination the cell in question, it is quite 
evident that the inspection of the contents of ovarian tumors is calculated 798 
SURGICAL DISEASES OF WOMEN. 
to facilitate a diagnosis. The plan of abstracting such contents may be 
properly considered in this connection. This can be accomplished by aspira- 
tion, by the abdominal trocar, by puncture, by the exploring needle, and by the 
hypodermic syringe. Simple as are these operations, they are not unattended 
with danger. Kiwisch, in an analysis of 130 tappings, reports a mortality 
of 17 per cent. The deaths are to be attributed to peritonitis, developed by 
the contact of some portion of the fluid contents of the tumor with the sur- 
face of the peritoneum, or to purulent infection, probably occasioned by the 
adriiission of air into the interior of the sac. Death has also happened from 
the trocar wounding a large vein distended over the sac, or, as in the case 
related by Scanzoni, situated in the omentum which covered the cyst. 
Of the different methods named, two should take precedence of all others, 
namely, the hypodermic syringe, or preferably the aspirator, unless the con- 
tents are gelatinous or semi-solid, when a large trocar can be substituted. 
A sufficient amount of fluid can be obtained for the purpose of examination 
by either of these instruments. In using the hypodermic syringe, after 
plunging the needle into the tumor at a point where the fluctuation is most 
evident, the piston of the instrument should be withdrawn, in order to suck 
out a portion of the liquid, which is often too tenacious and thick to run 
without aspiration. When the aspirator is employed, it is best to use a small 
trocar, and after drawing off the fluid to cover the puncture with a strip of 
adhesive plaster, and enjoin rest in the recumbent position in bed for three 
or four days, administering, if necessary, an opiate. 
The existence of a large accumulation of ascitic fluid may constitute a 
source of error if the tapping is carelessly done. This fluid is so unlike that 
furnished by an ovarian cyst, being thin and straw-colored, that its appear- 
ance during tapping is liable to be accepted as indicating no ovarian growth. 
Accordingly, after it is drawn off, the canula should never be removed until, 
by the touch, the abdomen has been explored, when it has often happened 
that a tumor is detected. If such is the case, and on percussion or palpation 
fluctuation can be detected, the trocar must be introduced and the sac punc- 
tured, when probably the liquid peculiar to ovarian disease will be discharged, 
and the diagnosis established. 
Incision.-An exploratory incision as a means of diagnosis is often a neces- 
sary antecedent to any radical operative measures. This should be made 
in the linea alba, below the umbilicus, and at first not exceeding one inch in 
length. Through this opening an examination of the growth may be made, 
and a steel sound can be introduced and swept round the exterior of the 
tumor, thus detecting adhesions if there are any. If more light is desired, 
the incision can be enlarged to any required extent. Of course all such 
exploratory openings are to be immediately followed by the formal opera- 
tion when the information obtained justifies such a procedure, and are to 
be made under the antiseptic spray. If the operation is deemed inadvisable, 
the wound must be dressed, and the treatment conducted in the same manner 
as after ovariotomy. 
An ovarian tumor in some instances is of a more solid variety than the 
cystic, being made up largely of glandular neoplasms, and can therefore be 
recognized only by an exploratory operation. 
It is always desirable, as far as possible, to ascertain not only whether the 
tumor is or is not ovarian, but also the variety of the cyst, whethei' unilocular 
or multilocular; whether or not there exist adhesions, and whether the ped- 
icle is long, short, or twisted. 
(1) When the tumor is of uniform surface, has had rapid growth, and the 
fluctuation is felt distinctly on the side opposite to wThere the palpation is 
applied, the presumption is in favor of a unilocular sac. 
Multilocular cysts, when exogenous, are somewhat irregular on the surface, 
and are less fluctuating, on account of the contents being generally consistent 
or gelatinous. Tapping wTill furnish valuable evidence as to the form of the 
cyst. When the cyst is unilocular, the fluid is usually of a straw or brown TUMORS OF THE OVARIES. 
799 
color, and of medium consistence. The tumor diminishes equally and uni- 
formly on all sides, as its contents are completely discharged through a single 
puncture. 
When the tumor is multilocular, its contents are thick and gelatinous, and 
before all can be removed it is necessary to direct the point of the trocar in 
different directions in order to puncture other cysts. The tumor, also, as it 
is emptied, diminishes or collapses unequally. 
(2) With reference to adhesions and their extent, it is impossible to pass 
beyond the region of conjecture antecedent to opening the abdomen; but 
there are some points worthy of attention. 
First, unilocular cysts are less likely to contract attachments to surround- 
ing parts than are multilocular. Secondly, a history characterized by the 
absence of abdominal tenderness or pain would be favorable to the non- 
existence of adhesions. Thirdly, freedom of movement, the tumor rolling 
from side to side as the patient changes her position, or settling into the 
pelvis without any sensation of dragging when the erect position is assumed, 
makes it probable that there are no inflammatory attachments. 
On the other hand, when the tumor has grown slowly, is multilocular, has 
been at different times accompanied with severe local tenderness and pain; 
when the walls of the abdomen cannot be readily slid over the tumor; or 
when, on placing the hand or the ear upon the parietes over different por- 
tions of the cyst, the patient breathing fully and rapidly, a friction or creaking 
sound is felt or heard, adhesions are certainly present. Much may be learned 
also by digital examination through the vagina. If, on making this while 
the pelvis is elevated, no recession of the uterus or of the dome of the vagina 
is detected, it is probably due to the tumor being tied down in the pelvis by 
inflammatory bands. 
There is no organ in the abdomen nor any portion of the parietes to which 
these ovarian tumors are not liable to become attached; and, while all such 
adhesions increase the difficulties and dangers of an operation, they are 
neither insuperable obstacles to the removal of the disease nor necessarily 
fatal to the success of the case. 
(3) An operator, when contemplating the extirpation of an ovarian cyst, 
considers, among other things, the pedicle of the tumor. When the cyst, 
with the lower part of the abdomen, projects well forward, overlapping the 
thighs, showing that the tumor rises above the brim of the pelvis, or when 
the tumor is not distinguishable through the wrnlls of the vagina, and the os 
uteri is higher than normal and the womb fully movable, we have a combina- 
tion of signs which signify a lengthy pedicle. 
If, on the other hand, the middle portion of the abdominal parietes as com- 
pared with the lateral is only moderately prominent, or if the uterus is low 
in the pelvis and abnormally fixed, or the tumoi' itself can be felt encroaching 
on the walls of the vagina, the existence of a short pedicle may be inferred. 
The mobility of an ovarian cyst, by permitting the tumor to revolve on 
its axis, exposes the pedicle to strangulation or twist, and such a condition 
may be conjectured when the patient is seized with severe uterine contrac- 
tions, or spasms of pain, situated in the region of one of the ovaries, and 
aggravated by changes in the position of the body, as when the patient turns 
on the side opposite to the one occupied by the pedicle. 
Duration of the disease.-The progress of ovarian dropsy, when left to itself, 
differs in different subjects. The drift of the disease is always to a fatal ter- 
mination, and this, in a majority of instances, occurs within three or four 
years, produced by peritonitis, exhaustion, or organic disease induced by 
mechanical pressure. Spontaneous cures are exceedingly rare. A lady at 
one time under my care preparatory to the removal of an ovarian tumor 
suddenly began to pass a large amount of what she supposed was urine. As 
this went on, the abdominal swelling diminished and finally entirely disap- 
peared. It was evident that the sac had contracted an adhesion to the blad- 
der, and a communication between the two had taken place by ulceration, 800 
SURGICAL DISEASES OF WOMEN. 
thus opening a convenient route for the escape of the fluid. The lady 
returned home, and had no return of the disease for over a year, when the 
same accumulation reformed, and again I was consulted with reference to an 
operation. Acting on the previous history of the case, I advised delay, 
and a second time the sac was emptied in the same way, since which time, 
now three years, no accumulation has taken place. 
In some instances ovarian tumors open into the colon or the rectum, or 
they may rupture and pour their contents into the abdomen. They have 
also been known to empty themselves through the walls of the belly. 
Circumstances promising a successful result.-In regard to the chances of 
recovery after an operation for the removal of an ovarian cyst, the prognosis 
will be highly favorable if the general condition of the woman is reasonably 
good; if the tumor is unilocular; if there are no adhesions; and, what is not 
the least important, if the patient is sanguine of her recovery. 
On the other hand, when the general health has been greatly broken down 
by long-continued irritation; when there is reason to believe that the tumor 
is multilocular, its contents gelatinous, and its walls bound to the parietes 
and the viscera of the abdomen by adhesions; and when, withal, the patient 
is depressed and despondent, the prospect of recovery is greatly lessened, 
though still by no means hopeless. 
Adhesions are present in about one-fifth of all cases of ovariotomy. In 
the table given on page 811, which embraces 5153 operations of this kind, 
adhesions existed in 975 cases, and no adhesions in 548. 
The influence of such attachments on the mortality of the operation is con- 
siderable. Of the 975 cases just referred to with adhesions, 662 recovered 
and 313 died,-a death-rate of 32.01 per cent.; while in the 548 without 
adhesions, 434 recovered and 114 died, or a mortality of 20.08 per cent. 
The place in which the operation is done exerts an important influence 
on the results of ovariotomy. Of 1916 operations, 1416 were performed in 
hospitals, with a death-rate of 35.09 per cent., while of 500 done in private, 
the mortality was 22.06 per cent. 
Again, antisepsis greatly lessens the mortality. Nothing can more forcibly 
illustrate this statement than the statistics of Keith. In the last 100 cases 
operated on by this surgeon under spray, 97 recovered, and in 75 successive 
operations he had not a death. In Germany, where the success of ovariotomy 
has not been so good as in other countries, the mortality by means of the 
antiseptic treatment has been reduced from 90 to 20 per cent. 
Mr. Wells, whose ovariotomies at present amount to 1000, and whose suc- 
cess is only exceeded by that of Mr. Keith, it is proper to say, does not 
attach much importance to antisepsis. 
Treatment.-Except through the methods of surgery, there is no way of 
deliverance open to a woman suffering from ovarian disease. 
The plans which have been employed are tapping, drainage, injection, and 
extirpation. 
Tapping.-This, the most ancient method, is performed by means of a trocar 
and canula, and can only be regarded as a palliative measure. The opera- 
tion can be executed when the fluid is thin by an ordinary hydrocele trocar, 
but when the contents are thick, a larger instrument will be required (Fig. 
Fig. 1509. 
1509), having a branch to which a piece of rubber hose can be attached for 
conducting the liquid into the vessels for its reception. 
Trocar for tapping an ovarian cyst. TUMORS OF THE OVARIES. 
801 
Thfe aspirator, from the little risk of air entering the sac when it is used, 
should be preferred to all other instruments for tapping, when not contra- 
indicated by the character of the contents of the tumor. The position which 
the patient should occupy is either sitting upon the edge of the bed, sup- 
ported by pillows placed against the back, or reclining on the side or on the 
back in bed, with the head and shoulders raised, the last being in most respects 
to be preferred. The place for making the puncture is about two inches 
below the umbilicus, in the median line, the skin having been incised to 
remove the resistance to the passage of the trocar, and the bladder emptied 
before puncturing the walls of the abdomen. 
When fluctuation cannot be detected over the course of the linea alba, and 
can be discovered elsewhere, this rule must be departed from, and the trocar 
introduced where fluctuation is most distinct, only taking care to avoid the 
position of the deep epigastric and circumflex iliac arteries. To facilitate the 
flow of the fluid, and to supply to the viscera the support lost by the removal 
of the liquid from the cyst, a many-tailed bandage should be placed around 
the body and tightened as the evacuation proceeds, on the completion of 
which, and after the removal of the canula, the opening should be covered 
with a strip of adhesive plaster and the tails of the bandage pinned together. 
When the tapping is performed with the patient on the side or on the back, 
the bandage will be unnecessary. 
When the tumor is multilocular, it will be necessary, in order to empty the 
sac entirely, to re-enter the trocar, and, by changing its direction and push- 
ing it forward, puncture other cysts or compartments of the tumor until all 
have been exhausted of their contents. 
Though I have tapped many ovarian tumors, I have never witnessed 
a death from the operation; and I am unable to understand why so for- 
midable a mortality as that usually given by authors should occur. May 
it not be attributed to the use of the large trocar, by which the opening 
in the sac is made too great, and to the sitting posture of the patient, both 
of which factors expose the peritoneum to the risk of contact with the sedi- 
mentary residue of the sac ? 
Cases of permanent cures following tapping have been given in numerous 
instances; but, while it is not to be denied that some are genuine, there is 
great reason to believe that the majority were not ovarian tumors at all, but 
cysts in the broad ligaments, which cysts are known frequently to disappear 
after being tapped. 
Tapping through the vagina.-When the tumor presents strongly at the 
upper part of the vagina, and when, on percussing the body*of the growth 
over the abdomen, fluctuation is felt by a finger placed against the projecting 
cyst in the vagina, the cyst should, preferably, be tapped through the latter. 
The advantages of making the puncture in this location must be evident, as 
not only is the sac more completely drained than when opened through the 
abdomen, but there is also little or no danger of the fluid subsequently enter- 
ing the peritoneum. It has been observed, too, that after tapping through 
the vagina the tumor refills more slowly, or may even undergo a spontaneous 
cure. In one case where I selected this route for tapping an ovarian sac, 
the accumulation did not recur for many months. Callison, it is stated by 
Kiwisch, was the first to perform tapping through the vagina, in 1775. 
In operating through the vagina, the patient, after having the bladder and 
rectum emptied, is placed on her back, with the head and shoulders raised 
and the limbs drawn up and flexed on the abdomen. The operator, seated in 
front, introduces the index finger of one hand into the vagina until its ex- 
tremity touches the most prominent part of the enlargement; then with the 
other hand a long trocar, with the point drawn within the canula, is con- 
ducted along the guiding finger to the protruding part, when the point of 
the instrument is thrust out and forced into the sac. On the withdrawal of 
the trocar the fluid can be received into a vessel properly placed below the 
pelvis. After emptying the cyst, the patient is to be placed in bed and kept 
VOL. II.-51 802 
SURGICAL DISEASES OF WOMEN. 
quiet for three or four days. Spencer Wells and others report cures follow- 
ing tapping; though the most that may be looked for is palliation. 
Tapping through the rectum is no longer practiced, the procedure being 
open to the risk of fecal or aerial extravasation into the sac. 
Drainage, introduced by Kiwisch, consists in puncturing the cyst by a 
trocar, either through the abdomen or through the vagina when the latter 
operation is practicable, and, after evacuating the fluid, introducing through 
the canula, before its removal, a drainage-tube. Noeggerath modifies the 
operation by expanding the vagina with a Sims speculum, and cutting through 
the upper extremity of the canal and the peritoneum until the sac is reached, 
which, being drawn through the incision, is opened freely, when the edges of 
the orifices thus made in the sac and the vagina are sutured together, estab- 
lishing a fistulous opening for draining away the liquid contents of the tumor. 
The sac is also injected, as occasion demands, with antiseptic agents through 
the fistula. Though Noeggerath has found even endogenous multilocular 
cysts disappear by this method, the plan is best suited to cases of unilocular 
tumors, the walls of which can collapse when once emptied. 
Injection has been practiced by Denman, Alison of Indiana, Boinet of 
Lyons, Baker Brown, and others. The substances employed were solutions 
of zinc and tincture of iodine, with iodide of potassium and water. The 
contents of the tumor being drawn off by a trocar and canula, a gum catheter 
is conducted into the sac by means of the canula, and the particular liquid 
selected is injected by means of a syringe fitted to its extremity, and, after 
being allowed to remain for fifteen or twenty minutes, is permitted to run out. 
The testimony of practitioners as to the curative value of this method, and 
as to the absence of danger from the iodine, is very conflicting. 
Thomas has tabulated 347 cases of ovarian disease treated by injection, 
which comprise the collections of Boinet, Cazeaux, Gunther, Simpson, Scan- 
zoni, West, Tyler, Smith, and Peaslee. Of this number, 117 are reported as 
cures, 95 failures, 79 deaths, and 56 doubtful. As in drainage, the cases 
deemed best adapted for injection are unilocular cysts whose contents are not 
thick and tenacious and which have not been the subjects of inflammatory at- 
tacks. It is not improbable that if the viscid, gelatinous material which so 
often adheres to the inner wall of the cyst could be destroyed, injection might, 
in properly selected cases, become a recognized mode of cure. Dr. Coates, 
of Leadville, Colorado, has furnished me the particulars of a case of ovarian 
dropsy which he successfully treated by the injection of eight ounces of the 
tincture of iodine, having cleansed the inner wall of the sac previous to 
injection by washing it with a strong solution of bicarbonate of soda. 
Znczsion was first performed by Le Dran in 1836, and consists in dividing 
the abdominal walls and the sac, and keeping the wound open by packing 
with lint, at the same time stitching together the parietes of the abdomen 
and the cyst, should no adhesion between the two already exist. The opera- 
tion is not likely to receive a very extended professional sanction. 
Excision, an imitation of an occasional natural cure by the rupture of the 
sac, allowing the fluid to escape into the cavity of the abdomen, was first 
performed by Guerin, and soon after by Bainbridge and by Jeaffreson. The 
operation consists either in puncturing the sac with a large trocar, and then 
closing the opening in the abdominal walls, or in exposing the cyst by an 
incision through the parietes of the body, dragging a portion of it through 
the opening, and, after excising a piece, pushing the tumor back and sewing 
up the abdominal wound. Such an operation can rarely be called for. 
The possibility of excising ovarian cysts had been considered as early as 
1685, by Schorkopff, and in France had been brought before the Royal 
Academy of Surgery in 1776. Laumonier, a French surgeon, it was sup- 
posed had actually, through a mistake as to the nature of the disease, re- 
Ovariotomy. OVARIOTOMY. 
803 
moved an ovarian cyst; but it has been satisfactorily shown that the tumor 
in question was an abscess connected with the Fallopian tube of the ovary, 
and not cystic. 
To Dr. Ephraim McDowell, of Kentucky, the world is indebted for ovari- 
otomy, one of the boldest operations within the domain of surgery, which 
this eminent man first performed in December, 1809, on the person of Mrs. 
Crawford, with entire success. McDowell's cases of ovariotomy amounted 
to 13, with 8 recoveries. Twelve years later, in 1821, Dr. Nathan Smith, 
of New Haven, removed, successfully, an ovarian cyst from a patient, the 
mother of several children; and this was followed, in 1829, by an operation 
performed by Dr. D. L. Rogers, of New York, the patient recovering; after 
which come the names of the two Atlees, Peaslee, Kimball, and Dunlap. 
In 1819, Chrysmar introduced the operation into Germany, where it was 
soon espoused by Dieffenbach, Heyfelder, and others. In 1827, Dr. Granville, 
of London, attempted to extirpate an ovarian cyst, but was compelled to de- 
sist on account of extensive adhesions. The first operation of the kind which 
was completed in London was by Mr. Phillips. The patient did not recover. 
The first successful removal was accomplished in the same city in 1840, by 
Mr. Walner. In England, however, ovariotomy was commended to the atten- 
tion of British surgeons in 1840, chiefly through the advocacy of Dr. Clay, 
who was supported by Lane, Spencer Wells, Baker Brown, and others. 
Lizars, in 1825, made an unsuccessful attempt to remove what he erroneously 
supposed to be an ovarian tumor. In Scotland, Keith-perhaps the most 
successful operator in the world-may be regarded as the representative 
ovariotomist. 
The history of ovariotomy is an instructive one. It not only inculcates a 
lesson which rebukes professional dogmatism and all prejudgments based on 
meagre data, but also demonstrates the heroic and dauntless spirit of those 
men who were willing to brave the storm of adverse criticism and censure, and 
who, sanguine of ultimate triumph, surmounted every difficulty, until finally 
opposition was silenced and universal commendation extorted. Dieffenbach 
condemned the operation, Kiwisch leveled against it a battery of statistics, 
and Scanzoni took sides with the opposition. In America, also, very dis- 
tinguished names were found among the objectors. 
Operation, Preparations, etc.-The time, the place, the preparatory meas- 
ures, the operative arrangements, the instruments, the technical details, and 
the after-treatment are all subjects demanding special consideration. 
Time for operation.-It is impossible to construct a rule on this point which 
shall govern all cases. Some contend that the operation, on account of its 
gravity, should be delayed until the health of the patient begins to suffer, as 
will be seen by the emaciation and loss of strength, and by the development 
of dyspeptic symptoms and other evidences of derangement of the internal 
organs, due to mechanical pressure. It is thought that by such a course the 
system acquires an increased degree of resistive power against morbid in- 
fluences, and that the peritoneum, by being subjected to the friction of the 
tumor, is rendered more tolerant of injury. On the other hand, some advo- 
cate operations done before the health declines, and before adhesions have 
formed between the tumor and the walls of the abdomen or its contents; and 
with this latter class of surgeons I entirely agree. An additional incentive 
to early operations is the avoidance of the mental anxiety and worry, which 
keep the woman constantly under a degree of excitement and suspense cal- 
culated to lower her vitality. 
Place.-A general hospital ward is not a suitable place for a patient who 
is to undergo this operation. A private apartment or a small ward is 
preferable, well ventilated, with an open fireplace which can be used in cold 
weather for preserving the proper temperature of the room,-that is, about 
75° or 80° Fahr.; it should have an exposure which will insure an abun- 
dance of sunlight. 
Preparatory measures.-These consist in securing a healthy action of the 804 
SURGICAL DISEASES OF WOMEN. 
secretory organs, as the liver, kidneys, and skin. To this end the bowels 
must be emptied of all accumulations by a gentle cathartic, the renal organs 
increased in activity by the administration of some diuretic, as infusion of 
digitalis or Basham's mixture, and the cutaneous organs stimulated by a 
warm or hot bath followed by friction of the surface of the body. 
The patient will do well to remain quiet in her apartment for a few days 
before the operation, in order to become accustomed to the constraint or 
quiet which must be enforced for some time succeeding the operation. The 
diet must be simple and unirritating, consisting of milk, oatmeal, and bread 
and butter, with meat once a day. Sleep must be induced by bromide of 
potassium dr chloral, or, if these fail, by administering a dose of deodorized 
laudanum at bedtime. The habitual employment of opium to procure rest 
is to be avoided, but it will prove of great value for one or two nights pre- 
ceding the operation, provided the patient is indisposed to sleep. On the 
morning of the day of the operation the intestines must be opened thoroughly 
by a large enema of warm water containing one or two tablespoonfuls of salt, 
or, in the event of there being any flatulent distention of the bowels, by an 
injection of flaxseed-tea and turpentine. 
The dress of the patient at the time of the operation should consist of a 
flannel undergarment, and over this a night-gown, the lower extremities 
being covered with stockings and drawers. 
A clear, bright day is always to be preferred, but the operation, after being 
fixed for a given time (mid-day the best), should not be postponed merely 
on account of the weather. The bed on which the patient is to lie should 
be a single one and covered with a firm mattress. The operating-table must 
be narrow, placed fronting a window, and covered with two or three com- 
fortables, over which is to be spread a muslin sheet, with a rubber- or oil- 
cloth for the purpose of protection. A bucket or tub to receive the contents 
of the sac should be placed under the table. 
Instruments.-As it is impossible to know before the sac is opened what 
complications may be encountered, it is the part of wisdom to be prepared 
for all emergencies. The following instruments, therefore, should be laid in 
a shallow tin vessel containing carbolized water, and placed on a small table 
convenient to the operator: an ordinary scalpel for incising the abdominal 
parietes and dividing strong adhesions, etc.; a pair of dissecting forceps; a 
grooved director on which to raise the layers of tissue to be incised; a few 
serres-fines, and a tenaculum to secure small vessels which bleed in the ex- 
ternal wound; a steel sound for passing between the tumor and the walls 
of the abdomen in search of adhesions; and a large trocar (Fig. 1510) with 
Fig. 1510. 
Trocar for tapping ovarian cyst after exposing the tumor. 
gum hose attached, for the purposes of puncturing the cyst and of convey- 
ing the fluid contents into the vessel beneath the bed. There are several 
patterns of this instrument, namely, that of Wells (Fig. 1511), which is 
armed with claws to grasp the sac and to keep the sides of the puncture in 
close contact with the instrument, and thus prevent the escape of the fluid 
between the sac and the canula; that of Hodge, which combines in one the 
canula and the trocar, the extremity of the former having a point similar to 
the needle of a hypodermic syringe; and that of Mears, which has a short 
arm capable of being bent at any angle with the rest of the instrument, on 
which movement depends the interruption or continuity of the canal of the 
canula. I have used all these varieties of instruments, and am disposed to OVARIOTOMY. 
805 
believe that the one shown in Fig. 1510 answers every purpose. In addition 
there will be required two pairs of vulsella for seizing and drawing the sac 
out and keeping it close to the walls of the canula, clamps for securing the 
Fig. 1511. 
pedicle, cautery irons, strong, carbolized silk thread, and, for the same pur- 
pose, silver wire, and a number of strong needles, straight and curved, for 
introducing sutures. The needle which I find most convenient for this pur- 
pose is similar to that which I use for sewing up the perineum or for ligating 
piles. (Fig. 1512.) 
Wells's trocar. 
Fig. 1512. 
Needle for sewing up the parietes. 
There are several clamps in use, examples of which are given in Figs. 
Fig. 1513. 
Atlee's clamp, open and closed. 
1513 and 1514. The one designated as Atlee's is perhaps the most desirable. 806 
SURGICAL DISEASES OF WOMEN. 
Besides the instruments specified, it will be necessary to have carbolized cat- 
gut ligatures for such vessels as bleed on separating adhesions; pieces of soft 
linen, well carbolized, 
upon which to spread 
portions of the omen- 
tum which require to 
be brought out of the 
abdomen; a number 
of soft sponges, thor- 
oughly deprived of all 
foreign substances and 
kept in glass-stoppered 
jars; sponge-holders; 
antiseptic gauze and 
cotton to apply over the 
surface of the wound 
when closed; a broad 
flannel bandage or band 
to envelop the body; and, finally, a large bucket of carbolized water (one 
part of carbolic acid to forty parts of water), several tin basins, a vessel 
into which the soiled water is to be thrown, and a spray apparatus. (Fig. 
1515.) The antiseptic solution should be made with phenol, the strength 
being one part of the acid to thirty parts 
of water. 
Assistants.-It is not desirable to have 
more assistants present than are necessary 
for the proper performance of the opera- 
tion. Five will be sufficient. To one is 
committed the anaesthetic; one is to aid in 
sponging and tying bleeding vessels; a third 
hands and receives instruments; the fourth 
will be employed in removing the soiled and 
furnishing clean water; and the fifth will 
Fig. 1514. 
Wells's clamp. 
Fig. 1515. 
Spray apparatus. 
supervise the spray. These assistants should not on the day of the operation 
have been engaged in dressing wounds or in attending to any infectious 
disease. Their clothing should be clean, and each should, preparatory to 
assuming his duties, wash his hands in carbolized water. 
Operation.-Everything being prepared, a chair is to be placed at the 
lower end of the table and a blanket spread over both. The patient being 0 VARIOTOMF. 
807 
placed on the table with her feet resting on the chair, and with the head and 
shoulders somewhat raised on pillows, her garments are to be rolled up above 
the waist in order that they may be kept dry, after which the blanket is 
to be wrapped about the limbs and the administration of the ether begun. 
The spray apparatus, placed on a stand in front of the table, must be regu- 
lated in such a manner that the vapor will be directed upon the parts to be 
incised. The operator now takes his position on one side of the patient and 
places his first assistant on the other, while the rest are disposed in such 
a mannei- as will enable each to perform his part without obstructing the 
light or interfering with the duties of the others. As soon as the patient 
is etherized, the bladder should be evacuated with the catheter, after which 
the formal operation begins. This may be divided into four parts,-namely, 
dividing the abdominal walls; tapping the cyst, separating any adhesions 
which exist, and tying bleeding vessels; securing the pedicle; and closing 
the wound. 
(1) Dividing the abdominal walls.-The incision must be made exactly in the 
median line, and between the symphysis pubis and the umbilicus, but nearer 
to the former. It should be short at first, not exceeding two inches in 
length. The layers of the parietes are to be divided with the scalpel alone 
until the muscular aponeurosis is reached, which should be raised on the 
grooved director and incised. The recti muscles being next separated, some 
cellulo-adipose tissue will be exposed, under which lies the peritoneum. Any 
vessels which bleed must be secured either by the animal ligature or by the 
serres-fines before the serous membrane is divided. Just at this stage of the 
operation a grave error may be committed. Mistaking the peritoneum for 
the walls of the cyst, the inexperienced operator may begin to peel the 
former away from the walls which it lines. A little attention will prevent 
the commission of this blunder. The peritoneum is covered with some fatty 
tissue, and is much thinner and not so pearly white as the wall of the cyst. 
The peritoneum being next laid open to the extent of the external wound, 
the dense, whitish sac of the tumor will be brought into view. A steel sound 
should then be introduced between the sac and the abdominal walls arid 
swept round, so as to detect the presence of adhesions over the anterior 
portion of the tumor, if any exist. 
Should any ascitic fluid be present, it is now discharged. If any adhesions 
are found to connect the cyst with the anterior wall of the abdomen, and they 
are not too strong, they may readily be broken up by passing the hand, first 
thoroughly cleansed of all blood and dipped in the carbolized water, between 
the two. If none are found to exist, the first part of the operation is com- 
pleted. 
(2) Emptying the sac.-The second step consists in tapping the cyst and re- 
moving its contents. The trocar and canula are plunged through the wall 
of the tumor into its interior, at the upper angle of the wound, and the trocar 
withdrawn, when the fluid will flow through the tubing into the vessel placed 
at the foot of the table for its reception. It is now that the vulsellum can 
be used with advantage by seizing the sac and holding it forward on the 
canula so as to prevent the fluid from entering the cavity of the abdomen. 
If the sac is a unilocular one, it will be entirely emptied through the single 
puncture; if multilocular, it will be necessary, after evacuating one, to push 
again the point of the trocar beyond the canula, and, changing its direction, 
thrust it through another cyst, and so on, until all have been drained. While 
the contents are flowing, the hands of an assistant may be applied on each 
side of the wound in the parietes, keeping up a steady pressure on the walls 
as they follow the receding or collapsing sac. 
When the cyst is multilocular and its contents so solid as not to pass 
through the canula, they must be removed by the hand, introduced and 
used as a scoop through a large opening made in the sac for this purpose. 
As soon as the cyst has been emptied, it is to be drawn by the vulsellum 
through the external opening until brought outside of the body, which, in the 808 
SURGICAL DISEASES OF WOMEN. 
event of no adhesion existing, can be done without difficulty. The pedicle 
will thus bo exposed and ready for treatment. 
Should adhesions fasten the tumor to surrounding parts, they must be 
detached. If these bands are extensive and strong, if they are found uniting 
the sac with the large intestines, the liver, uterus, bladder, or omentum, or 
if the tumor is multilocular and filled with endogenous cysts, in consequence 
of which it does not collapse, it will be necessary to prolong the incision 
upward through the walls of the abdomen even above the umbilicus, or to 
any extent which will enable the operator to see distinctly what he is doing. 
Many of the adhesions can be broken up by the fingers alone, always ob- 
serving to keep close to the wall of the cyst. Some which are dense will 
require to be touched with the edge of the knife, after which the separation 
can be continued with the fingers or the handle of the scalpel. Always be- 
fore breaking up these false bands a careful inspection of their attachments 
should be made, to see exactly to what the adhesion is fixed. Any neglect 
of this kind may result in the laceration of a large vessel, or possibly of the 
intestine or ureter. While the process of separation is in progress, every 
vessel which continues to bleed must be tied with the catgut ligature, and 
the blood or other fluid carefully mopped out of the cavity of the abdomen 
or pelvis by repeatedly using the carbolized sponges. When all adventitious 
connections have been separated and the tumor turned out, the next step is 
to secure the pedicle. 
(3) Securing the pedicle.-On this subject ovariotomists are not agreed. 
The methods most commonly adopted for treating the pedicle are by the 
clamp, the ligature, the cautery, and the ecraseur. 
When treated by the clamp,-the invention of Mr. Hutchinson, of Lon- 
don,-the pedicle, puckered into as small a space as possible by being sur- 
rounded with a stout ligature, is inclosed between its two branches, which are 
screwed tightly together, thus closing the vessels, after which the condensing 
cord above the clamp can be removed. The sac is then cut off above the 
clamp, when the latter is placed across the external wound outside of the 
abdomen. 
Ligature.-The ligature, when used to secure the pedicle, is employed in 
different ways. First, by transfixing with a double ligature and tying the 
two halves separately, cutting off the cyst, and securing the stump between 
the lips of the wound by passing a strong pin through all three. Second, by 
placing the stump, after being tied, in the wound, and covering its extremity 
with the skin, as done by Storer. Third, by returning the pedicle, after being 
tied and the sac cut away, into the abdomen, and bringing the threads out 
at the lower part of the wound, as advised by Clay, or through the vagina, 
an opening being made in the upper extremity of that canal for the purpose, 
-the plan of Greene. Fourth, by tying-the method of Tyler Smith-with 
a double ligature, cutting off both ends, and, after severing the sac, return- 
ing it into the abdomen,-a procedure which is adopted by Peaslee, Kimball, 
and Goodell, and which I have also practiced with success. The animal 
ligature has been used as a substitute for the silk thread in constricting the 
pedicle. Wire has also been used for the same purpose by Emmett and others. 
The peritoneum has in some instances been drawn over the end of the 
stump and united by sutures. 
Cautery.-The cautery, employed by Baker Brown, and at present by Mr. 
Keith, is applied by first embracing the pedicle with a clamp, then burning 
off the sac immediately above with a cautery iron, not raised to even a dull- 
red heat, after which the clamp is removed, and the edges of the stump care- 
fully smoothed off* by repeated passes with the hot (but not red-hot) iron, 
when the pedicle is restored to the cavity of the abdomen. 
Ecraseur.-Atlee at one time was an advocate of the ecraseur in severing 
the pedicle, the extremity of which he afterwards treated with persulphate 
of iron. 
* Sims's pamphlet on ovariotomy, by Keith. OVARIOTOMY. 
809 
Wells and Atlee are notably the champions of the clamp; and when a man 
counts his operations by the thousand, as is the case with the first-named 
gentleman, his opinion is entitled to the highest respect. Keith espouses 
the cautery, and its claim to professional confidence is based on a success 
in his hands which is unparalleled. In this cpuntry it has received the 
sanction of Sims and White. 
The merits of these different methods have become the subject of con- 
siderable diversity of opinion. In contrasting the relative success of the 
internal and external treatment of the pedicle by the clamp, the ligature, and 
the cautery, we find the following results: in 875 cases treated by the 
clamp the mortality was 21.25 per cent.; in 746 treated by ligature and 
dropped back into the pelvis, the death-rate was 32.17 per cent.; and in 66 
subjected to the cautery and returned into the abdomen, the mortality was 
9.09 per cent. Without entering further into the discussion, I think there 
are three modes of dealing satisfactorily with the pedicle, namely, by the 
clamp, by the cautery, and by the carbolized ligature, the stump being restored 
to the abdomen, and the thread cut off close. The clamp is best adapted to 
a long pedicle; the cautery and the ligature to a short one. 
Animal thread is scarcely trustworthy when the inclusion of a large mass 
of tissue is demanded, and the ecraseur, when used for the pedicle, may be 
followed by hemorrhage. 
How the strangulated portion of the pedicle is disposed of after the liga- 
ture is a question of absorbing interest. Theoretically, one might suppose 
that a raw surface and a devitalized stump, when allowed to come in contact 
with the peritoneum, would act as an irritant and develop a destructive peri- 
tonitis. Experience, however, has not verified such a supposition. I believe 
that all the evil effects spoken of are obviated by the extremity of the pedicle, 
when dropped back into the body, becoming encysted or encapsulated by a 
wall of lymph, within which it disintegrates, the products of the disinte- 
gration being carried away by the vessels which form in the walls that in- 
close the membrane. That such is the way in which the pedicle is disposed 
of will appear evident from a case of my own, in which, in removing a large 
multilocular cyst, I ligated the pedicle and returned it into the abdomen. 
The woman progressed without any unusual symptoms, and during my ab- 
sence from the city was permitted to get out of bed and to sit up on the four- 
teenth day. A sudden peritonitis followed, from which the patient sank and 
died in a few days. The autopsy revealed the end of the pedicle surrounded 
by a wall of lymph, which at one point had ruptured and allowed a creamy- 
looking fluid to escape through the opening into the peritoneum, from which 
rent lines of inflammatory lymph could be traced, radiating in all directions. 
To return to the operation. If, as sometimes happens, a second cyst exists, 
connected with the other ovary, it is to be treated precisely like the first. 
After securing the pedicle and removing the sac, the pelvis should be care- 
fully mopped out with the sponges, so that not a drop of blood or any other 
fluid is allowed to remain in the cavity. This must be repeated frequently, 
pressing the intestines and the uterus aside for the purpose, until everything 
appears dry. The last stage of the operation may now be commenced. 
(4) Closing the wound.-For this purpose I employ the needle represented in 
Fig. 1512, the eye of which is situated near the point. The sutures must in- 
clude all the layers of the parietes, cutaneous, fascial, aponeurotic, muscular, 
and peritoneal. The flap on one side being raised and somewhat everted 
between the thumb and fingers, the needle is entered about three-quarters 
of an inch from the margin of the wound and near its lower end, and brought 
out through the peritoneum an equal distance from its cut border. An 
assistant now passes a silver thread through the eye of the instrument, when 
the latter is withdrawn, thus conducting the wire through the opening. The 
needle is then unthreaded and passed through the opposite side of the wound 
in the same manner, when it is threaded with the peritoneal end of the wire 
and again withdrawn, thus completing the first suture. 810 
SURGICAL DISEASES OF WOMEN. 
The remaining sutures are to be inserted in the same manner, about half 
an inch apart. Each thread is to be left long and its ends twisted together. 
After all have been inserted, the flat sponge, previously placed underneath 
to catch any blood which should escape from the punctures, is to be re- 
moved, and a last look into the abdomen taken to see that no oozing has 
occurred, when, if all is dry, the sides of the wound are to be brought to- 
gether and the wires twisted and clipped off. If blood is detected in Doug- 
las's cul-de-sac, the sponge must be slipped in between the sutures and the 
fluid mopped out before the approximation is concluded. To prevent any 
accumulation of fluids in the pelvis, some introduce a drainage-tube, which 
is allowed to remain hanging out at the lower angle of the wound for a few 
days, and which, in the event of symptoms of infection arising, can be used 
as a medium for the introduction of disinfecting liquids into the abdomen, 
in order to wash out any decomposing fluids. It is better, I think, to delay 
the closure of the external opening for a short time, to see that no bleeding 
follows, rather than to insert these tubes. After the sutures have been ad- 
justed, a piece of lint moistened with carbolized oil, or the antiseptic gauze, 
is to be laid over the wound, and on top of this a sheet of carbolized cotton, 
all of which are to be held in place and at the same time the walls of the 
belly supported by enveloping the pelvis and the abdomen with a broad 
flannel or muslin binder, secured by pins. When the stitches are being 
introduced, the anaesthetic should be withdrawn and the patient allowed 
to return to consciousness. She is then to be placed in bed on her back, 
with bottles containing hot water and wrapped in flannel cloths applied to 
the sides of the body and the limbs; the weight of the bed-clothing should 
be supported by a cradle. 
After-Treatment.-If the operation has been a simple one and not pro- 
longed, there will probably be very little shock experienced, in which case 
nothing is required but absolute quiet. Thirst is to be relieved by cracked 
ice, and if the patient is restless an anodyne is admissible. 
Should the shock be great, every effort must be made to secure reaction 
by external warmth and by the cautious use of enemata of brandy. A 
common after-effect of the anaesthetic and the operation is vomiting. This 
is sometimes very obstinate. It is best relieved by sinapisms over the epi- 
gastrium, an occasional mouthful of hot water, or by carbonic acid water, 
and often by ice. If these remedies are not sufficient to overcome the retch- 
ing and vomiting, it may be well to administer a hypodermic injection of 
morphia. In instances of protracted gastric irritability following ovariotomy 
I have seen very good effects from the administration of minute doses of 
calomel and morphia repeated at short intervals, for example, one-eighth of 
a grain of the mercurial with one-thirtieth of a grain of morphia every hour. 
The urine must be drawn three times in the twenty-four hours for the 
first six days, after which the patient may pass it. The bowels need not be 
opened for seven or eight days, and then an operation is best secured by an 
enema of soap and water, or, if there is much flatulence, by one of flaxseed- 
tea and turpentine. 
Diet.-For the first three days the patient should be allowed only a table- 
spoonful of milk, with a little lime-water, once every three or four hours. 
Small pieces of ice may be used without much restriction. After the third 
day the quantity of milk can be increased, and some beef-tea may be allowed. 
If everything progresses well, the sutures can be removed at the end of eight 
or nine days, and the patient allowed to sit up for a short time after the lapse 
of fourteen days. 
Sequels.-The complications which are likely to arise are collapse, hemor- 
rhage, septic poisoning, and peritonitis. Shock usually follows immediately 
after the operation, and, as has been already stated, reaction is best secured 
by external warmth, the use of stimulating enemata, and the moderate em- 
ployment of anodynes. 
Hemorrhage, should it ensue, is seldom delayed beyond twenty-four hours, OVARIOTOMY. 
811 
and, when internal and clearly recognized, will require that the wound be 
opened, the bleeding vessels sought out and tied, and the blood carefully re- 
moved from the pelvis before reclosing the external opening. The necessity 
for such a measure is unfortunate, but there is no alternative. If the bleed- 
ing proceeds from the stump, it should be uncovered and touched with the 
actual cautery. 
Septcemia is not likely to occur earlier than the fifth or later than the 
fourteenth day. In most instances the infection is to be attributed to the 
decomposition of blood or other liquids which collect in the cavity of the 
peritoneum; and hence the importance of not closing the external wound 
until it is certain that all oozing has ceased. 
The signs of septfemia are a frequent pulse, an elevated temperature, great 
prostration, parched tongue, and mild delirium. Sometimes these signs are 
preceded by a rigor. Few patients laboring undei' this affection ever re- 
cover. The treatment does not differ from that proper to septsemia succeed- 
ing other operations. 
Peritonitis.-About twenty-five per cent, of the mortality following ovari- 
otomy is due to peritonitis. The precautions which lessen the probability 
of septsemia are equally influential in preventing inflammation of the peri- 
toneum, in addition to which it is important to maintain a quiet state of 
the abdominal and pelvic viscera for at least seven or eight days. This indi- 
cation will be fulfilled by the frequent use of the catheter and by the very 
moderate use of opium in some form. 
The symptoms which reveal peritonitis are extreme abdominal tenderness 
and distention, with a frequent, hard, and contracted pulse. 
The prognosis in a case of peritonitis will be extremely gloomy. Opium, 
hot poultices over the abdomen, and stimulants if the prostration is very 
marked, constitute the remedies at our command. The local abstraction of 
blood is generally contra-indicated by the accompanying prostration. 
The following tables, embracing an analysis of 5153 cases of ovariotomy 
collected by Dr. Baum, present in a condensed form the leading and most 
interesting features connected with this operation. 
Table containing an Analysis of 5153 Cases of Ovariotomy. 
Cases, 
Recovered. 
Died. 
Percentage 
of Mortality. 
Total 
5153 
3651 
1502 
29.13 
Single operations 
4969 
3531 
1438 
28.94 
Double operations 
183 
120 
63 
34.42 
Triple operation 
1 
0 
1 
100.00 
Twice on same patient 
15 
12 
3 
20.00 
During pregnancy 
21 
17 
4 
19.05 
During septicsemic fever , 
40 
36 
4 
10.00 
Tumors extirpated per vaginam 
5 
5 
0 
0.00 
Adhesions 
975 
662 
313 
32.01 
No adhesions 
548 
434 
114 
20.08 
Treated in hospital 
1416 
909 
507 
35.09 
in private 
500 
387 
113 
22.60 
" in nursing homes 
49 
35 
14 
28.57 
Pedicle secured by clamp 
875 
689 
186 
21.25 
Ligated and dropped into the pelvis 
746 
502 
244 
32.17 
Ligature left outside 
309 
187 
122 
39.48 
Cautery 
66 
60 
6 
9.09 
Cautery and ligature 
14 
10 
4 
28.57 
Ligature and clamp 
53 
36 
17 
32.07 
Pin and ligature as clamp 
17 
11 
6 
35.29 
13 
10 
3 
23.08 
Silver wire (Sims) 
10 
9 
1 
10.00 
Secured to wound by pins 
15 
8 
7 
46.66 
No pedicle 
5 
4 
1 
20.00 
Ecraseur 
4 
3 
1 
25.00 
Pin and ecraseur • 
1 
1 
0 
0.00 
Twisting 
1 
1 
0 
0.00 
Sewed to abdominal walls 
1 
0 
1 
100.00 
Vaginal drainage 
86 
65 
21 
24.41 • 812 
SURGICAL DISEASES OF WOMEN. 
Ages, with Number of Married and Unmarried, in 1123 Cases of Ovariotomy. 
Ages. 
Un- 
mar- 
ried. 
Recovered. 
Died. 
Married. 
Recovered. 
Died. 
Under 15 years. 
10 
8 
2, or 
20.00 per cent. 
0 
0 
0 
15 to 20 years. 
55 
41 
14, or 
25.45 
ll 
2 
2 
0 
20 to 25 
99 
73 
26, or 
26.26 
ll 
36 
29 
7, or 19.44 per cent. 
25 to 30 
ll 
82 
55 
27, or 
32.91 
ll 
90 
68 
22, or 24.44 
ll 
30 to 35 
ll 
59 
37 
22, or 
37.28 
ll 
110 
85 
25, or 22.72 
ll 
35 to 40 
ll 
40 
26 
14, or 
35.00 
ll 
120 
80 
40, or 33.33 
ll 
40 to 45 
ll 
27 
21 
6, or 
22.22 
ll 
83 
60 
23, or 27.71 
ll 
45 to 50 
ll 
20 
11 
9, or 
45.00 
ll 
98 
69 
29, or 28.56 
ll 
50 to 55 
u 
33 
19 
14, or 
42.42 
ll 
53 
35 
18, or 33.96 
If 
55 to 60 
n 
10 
5 
5, or 
50.00 
ll 
55 
42 
13, or 23.63 
If 
60 to 65 
n 
8 
7 
1, or 
12.50 
ll 
18 
13 
5, or 27.77 
ll 
65 to 70 
u 
0 
0 
0, or 
0.00 
ll 
9 
7 
2, or 22.22 
ll 
70 and upward. 
1 
0 
1, or 100.00 
ll 
5 
2 
3, or 60.00 
ll 
444 
303 
679 
492 
In 960 cases of ovariotomy analyzed with a view to determine the influence 
of the length of the incision on the mortality, it appears that when the in- 
cision did not exceed 4 inches the death-rate was 20.68 per cent.; when over 
4 inches and not exceeding 6 inches, 23.04 per cent.; when over 6 inches and 
not exceeding 7 inches, 40 per cent.; and when between 7 and 8 inches, 
42.88 per cent. Antiseptic treatment would certainly reduce the mortality 
very much. 
Principal causes of death.-Peritonitis, in 332 cases; shock, 50; septic 
peritonitis, 12; hemorrhage, 32; septicaemia, 38; exhaustion, 25; intestinal 
troubles, 13; tetanus, 6. 
Hydrops Tubarum, Hydrosalpinx, or Tubal Dropsy.-Dropsy of the Fal- 
lopian tube is not a very common affection. It may be unilateral or bilateral. 
The tumor rarely attains any great size, and is the result of an inflammatory 
closure of the tube from adhesion of the serous surfaces of the fimbriae, some- 
times following pelvic cellulitis, peritonitis, or catarrhal states of the mucous 
lining of the canal, and occasionally resulting from a twist of the ovary. 
Both the uterine and abdominal extremities of the tubes may be occluded. 
The fluid which accumulates is generally clear or yellowish in color, and 
coagulates on the addition of heat and acids. As the distention of the tube 
progresses, its walls become attenuated, the muscular layer is separated into 
straggling bands, and the plications of the mucous membrane are gradually 
unfolded and stretched, until finally all its normal characteristics of structure 
disappear. The tumor does not present the appearance of an elongated 
cylindrical sac, but by doubling on itself assumes a shape not unlike that of 
a distended colon. 
There are no symptoms which enable the surgeon to distinguish between 
this tumor and any other cyst, either of the ovary or of the broad ligament. 
A mobility distinct from that of the uterus, and the irregular, nodulated 
outline,-peculiarities which are said to characterize these growths,-are so 
common in ovarian tumors that no reliance can be placed upon their presence 
as a means of diagnosis. 
Tubal dropsy may terminate spontaneously by the giving way of the 
uterine orifice of the tube and the escape of its contents into the womb. 
When this termination does not take place, the cyst should be tapped by 
the aspirator through the upper part of the vagina. After the withdrawal 
of the fluid the disease is not likely to return. 
Cysts of the Broad Ligaments.-Cysts of the broad ligaments are met -with OVARIAN FIBROMATA. 
813 
either in the canals of the Wolffian body, or, entirely independent of these, 
between the folds of the peritoneum. They are for the most part unilocular, 
and in the former situation are rarely larger than an orange; in the peri- 
toneum they attain a much greater magnitude. 
These cysts have frequently been confounded with ovarian tumors. The 
diagnosis of those exterior to the Wolffian body, as pointed out by the late 
Dr. Washington Atlee, may be established by examination of the fluid con- 
tents of the cyst, which are very thin, translucent, sometimes opalescent in 
the light, and non-albuminous. 
Treatment.-These cysts are to be tapped, and their contents removed; 
the collapse of their walls is usually followed by a cure; or, after the punc- 
ture, the opening in the parietes of the abdomen may be closed, and the fluid 
allowed to escape into the peritoneal cavity. As it slowly drains away, 
the sac gradually contracts and becomes obliterated. 
Dermoid Cysts.-Dermoid cysts, sometimes called histoid tumors, from the 
similarity of their contents to the tissues of the animal body, do not, as a rule, 
attain any great size, seldom exceeding that of a small foetal head. 
For a long time these growths were considered to be the products of a 
conception which had failed to reach the Fallopian tubes, but was retained in 
the ovary. This view is no longer tenable, as cysts of this nature are not 
necessarily connected with the ovary. The solution of the question of their 
growth will probably be found in some defective development of certain por- 
tions of the germinal layers of the embryo. These cysts are always con- 
genital in their origin, but may remain quiescent or 
make little progress until after that sudden evolu- 
tion which the sexual organs undergo at puberty; 
or they may be excited to growth by the stimulus 
of parturition. The contents of these cysts consist 
of bone, fat, hair, teeth, skin, a porridge-like sub- 
stance, cholesterin, and various animal products. 
(Fig. 1516.) 
Dermoid cysts are not always found alone, but 
may exist associated with multilocular tumors of 
the ovary. There are no symptoms which declare 
the presence of these cysts, and consequently they 
are likely to be confounded with ovarian tumors. 
Dr. Mears, of Philadelphia, removed one from a 
child six years old, which was, before the opera- 
tion, supposed to be ovarian. A similar case is 
reported by Spencer Wells. 
Cysts of this kind not unfrequently reveal their true character by con- 
tracting adhesions to surrounding organs and discharging into them their 
contents. Thus, they frequently empty into the rectum, into the vagina, or 
into the bladder. In one case I witnessed the discharge occur at the umbili- 
cus in a lady several months after delivery. When the disease takes this 
course, the process of extrusion should be left entirely to nature. Unless 
dermoid cysts occasion very serious evils by mechanical pressure, it is better 
not to resort to operative measures. 
Fig. 1516. 
Dermoid cyst in the ovary, con- 
taining hair, fat, and one tooth.- 
From specimen in the Museum of 
the University of Pennsylvania. 
Ovarian Fibromata.-Fibromata of the ovary are quite uncommon, and 
when present are prone to undergo a cystic or osseous degeneration. They 
are the counterpart of similar tumors in the uterus, and cannot be diagnosed 
with certainty from other tumors of the ovary. Their regularity of outline 
and slowness of growth will aid in some degree in distinguishing them from 
carcinoma, while their solidity will furnish ground for not confounding them 
with cysts of the ovary. 
Only when, from pressure, the disease begins seriously to affect the health 
should an operation (that of extirpation) be contemplated. 814 
SURGICAL DISEASES OF WOMEN. 
Carcinoma, like fibroma, is rare. It is likely to attack both ovaries simul- 
taneously, and is not peculiar to any age, being seen both in the young and 
in the middle-aged,-the former perhaps being oftener subject to the disease 
than persons of more mature life. 
It is more commonly met with as a secondary disease, following cancer of 
the uterus, rectum, or more remote organs, and generally conforms in char- 
acter to that of the primary disease; that is, if the latter is encephaloid, 
which is most commonly the case, the ovarian carcinoma will be of the same 
type; this is equally true if the original tumor is an epithelioma, a scirrhus, 
or a colloid growth. 
When carcinoma of the ovary breaks through its envelope-the peritoneum 
-the disease will extensively invade the latter. Ovarian carcinoma com- 
mences in the epithelium of the follicles of the ovary, and as the tumor 
enlarges it may undergo cystic degeneration. 
As a rule, ovarian carcinoma is not well tolerated by the surrounding 
parts. Growing rapidly, it excites a chronic peritonitis, giving rise to a large 
accumulation of ascitic fluid in the abdominal cavity, covering the surface of 
the tumor with soft plastic deposit, and often gluing it to the parietes of the 
body. The inflammation is likely to extend to the connective tissue of the 
pelvis. 
The diagnosis of ovarian carcinoma will be rendered probable by the ex- 
istence of a bilateral tumor in both ovarian regions sensitive to the touch, 
an early accumulation of serum in the cavity of the abdomen, emaciation 
and loss of strength, and a fixed state of the uterus from an existing pelvic 
cellulitis. 
Little can be done for the relief of a patient suffering from this affection, 
except in the wTay of palliation by the use of anodynes. 
Sarcoma begins in the connective tissue of the ovary. Like cancer, it is 
prone to attack both ovaries, is of the spindle-celled variety, rarely round, 
and may attain a very great size. Its general history, progress, rationale, 
and other phenomena do not furnish any clue by which it can be distin- 
guished from carcinoma, nor will the treatment differ from that which is 
proper to the latter. 
Enchondroma has rarely been found affecting the ovary. Sometimes this 
neoplasm has been seen imbedded in an ovarian fibroma. 
Tubercular formations of the ovary are uncommon, but occur occasionally 
in the young as a part of a more general tuberculosis affecting the lungs, 
kidneys, or testes. The tubercles may be seated both in the stroma and in 
the serous surface of the ovary. 
Hydrocele of the Round Ligament.-The round ligaments of the uterus 
follow the course of the spermatic cords in the male, terminating in the labia 
majora. The true peritoneal investment of the ligaments in the adult stops 
at the internal abdominal rings. From this point downward, along the canal 
into the labia, the enveloping membrane, though originally a portion of the 
peritoneum, consists simply of fibrous tissue. When the peritoneum is pro- 
longed through the internal abdominal ring into the canal, the pouch so 
formed is called the canal of Nuck. When this remains open, a collection 
of fluid is liable to form in the sac, constituting hydrocele of the round liga- 
ment, or a portion of intestine may descend into the canal, forming a hernia. 
Even the ovary may prolapse into this tubular pouch. 
Hydrocele of the round ligament is liable to be confounded with hernia; 
but the translucency of the swelling, the absence of resonance on percussion 
peculiar to enterocele, or of the doughy feel of an epiplocele, and, above all, 
the information supplied by the exploring needle, will enable the practitioner 
to clear away any obscurity which may exist as to the nature of the enlarge- 
ment. 
Treatment.-The treatment consists in puncturing the sac with a delicate PERI- UTERINE HJEMA TO CELE. 
815 
trocar, and, after evacuating its contents, scratching its interior with the point 
of the instrument before removing the canula, and afterwards applying a 
compress and a spica bandage, and for a few days the pad of a gently-press- 
ing truss over the canal. Should this plan fail to effect a cure, the sac may 
be injected with one drachm of tincture of iodine while the patient is in the 
erect position, pressure at the same time being made over the seat of the 
internal ring, in order that the fluid may not enter the abdomen. 
Peri-Uterine Haematocele.-Peri-uterine hrematocele, sometimes described 
as retro-uterine hsematocele, is a collection of blood around or behind the 
uterus, either within or beneath the pelvic peritoneum. When within the 
serous cavity of the membrane, the blood gravitates to the bottom of Doug- 
las's cul-de-sac (Fig. 1517), and when it is beneath the peritoneum, it infiltrates 
the connective tissue of the pelvis, extending around the neck and body of 
the uterus. (Fig. 1518.) 
Fig. 1517. 
Fig. 1518. 
Hfematocele in Douglas's cul-de-sac. 
Subperitoneal haematocele. 
The credit of first describing correctly the nature of this tumor is due to 
Nelaton, though his claims to priority have been warmly disputed by Ber- 
nutz, who prefers to name this condition peri-uterine hsematocele. 
Source of the Blood.-This will depend on the situation of the haama- 
tocele. When the collection of blood is within the cavity of the peritoneum, 
it is commonly derived from the vessels of the ovary, and occasionally from 
those belonging to the false membranes of old peritonitis (as pointed out by 
Virchow), the walls of which have given way. When the extravasation 
exists below the peritoneum in the cellular tissue of the pelvis, the blood 
■will probably have been derived from the tortuous veins which lie between 
the folds of the broad ligaments or the vessels around the lower parts of 
the body of the womb. The opinion once entertained that this blood, when 
existing within the sac of the peritoneum, is regurgitated menstrual blood, 
finds, I believe, no advocates at present. 
Causes.-The causes of peri-uterine hsematocele are predisposing and ex- 
citing. 
These hemorrhages usually occur at that period of life when the sexual 
organs are most active, or during menstruation, or in the course of chronic 
uterine disease: anything, therefore, which induces an undue fullness of the 
uterine and ovarian blood-vessels may be considered as a predisposing cause. 
The exciting causes are inordinate sexual excitement during coition, 
mechanical violence, and suppression of the menstrual flow. 
Symptoms.-The symptoms of peri-uterine hsematocele are by no means 
uniform, a fact which must be ascribed to the manner in which the hemor- 816 
SURGICAL DISEASES OF WOMEN. 
rhage occurs, whether slowly or suddenly. Generally there is experienced, 
especially in the subperitoneal variety of the hsematocele, more or less pain 
in the pelvis, which is at first referred to the region of the ovaries, and is 
accompanied or followed by a sense of fullness or weight. As the accu- 
mulation of blood progresses, the effects of pressure become apparent. Un- 
easiness or pain will be felt extending down the thighs and to the hips, from 
the encroachments of the blood on the sacral plexus of nerves. Irritability 
of the bladder, followed by frequent micturition or by retention of the urine, 
will be present from the same cause, and so also will difficulty in defecation. 
When an examination is made through the vagina, the finger detects a 
tumor, generally posterior to the cervix (rarely anterior), and crowding 
the uterus against the pubes, so that the former is quite immovable. The 
tumor is sometimes elastic, at other times hard at one place and soft or 
doughy at another, according as the blood is found in a fluid or coagulated 
state. The pains are frequently very severe, even agonizing, accompanied 
by nausea, pallor of the face, vomiting, a cold skin, and a small, feeble, 
frequent pulse. 
If a large hemorrhage takes place into the cavity of the peritoneum, a 
tumor may be felt through the abdominal parietes above the pubes. This is 
not likely to be the case when the hsematoeele is in the cellular tissue of the 
pelvis, as the resistance which is offered by Douglas's cul-de-sac prevents such 
upward extension. When the accumulation of blood is large in cases of sub- 
peritoneal hiematocele, the peritoneum may be ruptured and the extrava- 
sation of blood escape from the cellular tissue of the pelvis into the cavity 
of the peritoneum, in which case the two varieties of the affection will be 
merged into one. 
The following phenomena will serve to establish the distinction between 
an intra-peritoneal and a subperitoneal hsematocele: 
INTRA-PERITONEAL HEMATOCELE. 
Constitutional symptoms very marked; uterus 
anteverted, or thrust to one side. 
The swelling or tumor discernible at the top of 
the pelvis. 
The color or tint of the mucous membrane of 
the vagina natural. 
Peritonitis common. 
SUBPERITONEAL HEMATOCELE. 
Not necessarily so; uterus elevated. 
Tumor low down in the pelvis. 
Purple or red color in consequence of pressure 
on the veins of the pelvis. 
Uncommon. 
Prognosis.-The prognosis will depend on the severity of the hemorrhage 
and its location. Generally the danger is greater in the intra-peritoneal than 
in the subperitoneal variety. 
In the majority of instances the blood is gradually absorbed, requiring 
frequently many months for its final disposition by this process. Sometimes 
it finds its way, after a considerable length of time, into the rectum or vagina 
and is discharged. 
Treatment.-The indications are to arrest the hemorrhage, to counter- 
act the effects of prostration and alleviate local suffering, and to secure the 
absorption of the blood. The first indication is most satisfactorily fulfilled 
by removing all constriction of clothing about the body, elevating the pelvis, 
and applying an ice-bag or cloths wet in ice-water over the lower part of the 
abdomen. Vaginal injections of ice-water, with absolute rest, and hypodermic 
injections of fluid extract of ergot, arc also of value in stopping the flow of 
blood. 
To establish reaction and relieve pain, stimulants will be required in mod- 
eration, and hypodermic injections of morphia. 
When there is much nausea, champagne will prove useful in slaking the 
thirst and allaying the irritability of the stomach. The extent to which the 
anodyne should be administered must be determined by the amount of de- 
pression and the severity of the pain. 
As soon as the urgency of the symptoms is over and the stomach has PELVIC CELLULITIS. 
817 
become quiet, liquid nourishment will be required, milk and bccf-essence 
being most suitable for the purpose. 
The propriety of evacuating collections of blood in hematocele has not 
been overlooked by surgeons. Recamier resorted to operative measures for 
this object. The evacuation was effected by exposing the bulging portion of 
the tumor in the vagina and either puncturing the enlargement by means of 
a trocar and canula, or incising the overlying tissues and turning out the clots 
with the finger or a scoop. The aspirator might be used for the removal 
of the more fluid portions of the collection. After emptying the accumula- 
tion the cavity is to be washed out once every day with antiseptic injections. 
The results of operations, however, have been less favorable than those of 
natural processes, and consequently these practices soon fell into discredit 
as well as into disuse, so that any resort to operative measures in cases of 
hsematocele would now be justifiable only in cases of extreme necessity. 
Iodide of potassium is thought by some to exert a favorable effect in securing 
the absorption of the extravasated blood; but in my judgment time, tonics, 
and good diet are the chief factors in this process. 
A patient who has once suffered from hemorrhage of this nature must be 
extremely prudent as she approaches her next menstruation, for feai* that 
the attack may be renewed. Therefore it will be highly proper for her to 
remain quiet in bed for three or four days previous to her monthly periods 
and during that time for at least two or three subsequent menstruations. 
Sequelae.-Hiematocele is liable to be followed by peritonitis, pelvic cellu- 
litis, and the formation of inflammatory bands, causing displacements of the 
uterus, painful menstruation, etc. 
Peritonitis will demand the application of turpentine stupes, of hot poul- 
tices over the abdomen, warm vaginal douches, and opium internally. 
Pelvic Cellulitis. 
Beneath the pelvic reflections of the peritoneum, between the broad liga- 
ments, and between the vagina and the uterus, and the bladder and the 
rectum, there exists a quantity of loose connective tissue, through which run 
a large number of blood-vessels and nerves, and which serves the triple pur- 
pose of supporting the latter, preventing displacement of the pelvic viscera, 
and at the same time allowing a certain degree of movement between the 
organs of the pelvis. 
Inflammation of this connective tissue is designated by various terms, as 
pelvic cellulitis by Grailly Hewitt and Simpson, peri-uteritis by Courty, peri- 
metritis by Virchow, and peri-uterine cellulitis by Thomas. Although the 
disease was undoubtedly recognized by the older surgeons and obstetricians 
under different names, it is only within the last thirty-five or forty years that 
it has been correctly described, chiefly through the labors of the French and 
English. 
Some writers, and notably among them Dr. Matthews Duncan, regard 
these inflammations of the cellular tissue of the pelvis as always secondary 
to inflammation of the uterus, ovaries, etc. That this is frequently the case 
no one will doubt; but it is not always so. The mode of blood-supply to the 
uterus, ovaries, and vagina is not corroborative of such a view, as these 
organs receive their supply after the cellular tissue has been served. Emmett 
is disposed to give to phlebitis a prominent place in the causation of the 
disease. Pelvic cellulitis is more common in married than in unmarried 
females. It may be either local or general, and, according to Emmett, is 
more frequently met with on the left side; being situated there in sixty-four 
out of one hundred and fifty-seven cases. The disease is rare after the 
menopause. 
Causes.-Among the causes which give rise to inflammation of the cel- 
lular tissue of the pelvis are inflammatory conditions of the uterus and of 
the ovaries, hsematocele, sudden suppression of the menses, laceration of the 
vol. ii.-52 818 
SURGICAL DISEASES OF WOMEN. 
cervix uteri, injuries to the vagina from the maladroit use of instruments 
in difficult labors, long retention of the foetal head in the pelvis, and severe 
concussions of the pelvic viscera. 
Puerperal conditions are undoubtedly the most frequent causes of this 
disease. It also appears occasionally to be hereditary. I recall three sisters, 
each of whom suffered from the disease, and all after first labors. 
Symptoms.-In the acute form of pelvic cellulitis the disease is usually 
announced by a rigor or chill, followed by fever, the temperature running up 
to 102° or 103°. Pain is felt in the hypogastric region, and often there is 
tenderness over one or both iliac regions, possibly over the entire lower half 
of the abdomen. The contiguity of the bladder and rectum to the inflamed 
tissue renders urination and defecation painful. In other cases the disease 
may progress so insidiously that its true nature may pass for some time un- 
detected, causing very little or no pain, and characterized only by an evening 
exacerbation of fever, with some deep-seated sense of fullness or weight in 
the pelvis, especially noticeable during defecation or when making any strain- 
ing efforts. 
The physical signs communicate the most decisive information in this affec- 
tion. When the congestive stage of the disease has terminated in transu- 
dation, if a finger is introduced into the vagina and carried up to its source, 
pressing carefully in different directions on all sides of the cervix uteri, and 
especially well up towards Douglas's cul-de-sac, increased heat and tender- 
ness of the parts will be detected, and if during the vaginal examination 
the surgeon employs external abdominal pressure, while the body is raised 
and the limbs well drawn up, a distinct tumor or hardness may be dis- 
covered, circumscribed or diffused, and answering to the plastic infiltration 
of the connective tissue of the pelvis. Often it will be found that a digital 
exploration through the rectum, especially when the induration occupies the 
posterior portion of the pelvis, will convey the most satisfactory informa- 
tion. Later on in the progress of the disease the uterus, especially when 
the pelvic peritoneum participates in the inflammation,-by no means an 
uncommon complication,-becomes displaced and fixed, so as often to admit 
of very little, if any, movement. 
Termination.-Pelvic cellulitis, should it not pass into a chronic state, 
seldom continues longer than two or three weeks, ending either in resolution 
or in suppuration. When the disease follows the former course, the local 
and general symptoms gradually disappear, and the uterus assumes approxi- 
mately its normal position and mobility; or if adhesions have formed, and 
have become sufficiently organized to resist retrograde metamorphosis, the 
organ may remain permanently displaced. 
In the event of suppuration, the pus is sometimes confined to a single 
locality, or the abscesses may be multiple, and after a time connect with one 
another by direct or circuitous routes, until the connective tissue of the pelvis 
is riddled by the sinuses. The pus finds its way out of the body by various 
routes, as through the vagina, the bladder, the rectum, the upper intestine, 
the abdominal wralls, or the perineum, by the side of the anus, or through 
the saphenous opening upon the thigh, and sometimes by some of the open- 
ings which lead from the pelvis, as the obturator or ischiatic. In a few 
instances, instead of a single sinus several are present. A lady under my 
care has three of these openings on the thigh, two on the lower part of the 
abdomen, and one alongside of the tuber ischii. 
Prognosis.-In a large number of cases recovery ultimately takes place, 
even though the disease may end in suppuration. In the mean while, how- 
ever, the patient will probably suffer from frequently-recurring attacks of 
pelvic distress, chills, and pyaemic fever, with loss of appetite and strength, 
due to the repeated filling up and emptying of the old abscesses, the walls 
of which contract very slowly and may not become entirely obliterated for 
many months, perhaps for years. Even when a case is going on favorably 
there is risk of the circumscribing barriers of the abscess giving way, allow- PELVIC CELLULITIS. 
819 
ing the pus to invade other regions, as the iliac, or, even without such acci- 
dent, an attack of peritonitis may destroy life. 
Even when recovery is assured, the remote consequences of the disease 
are often a source of no small degree of physical suffering to the woman ; 
as, for example, uterine displacements, menorrhagia, dysmenorrhoea, sterility, 
disorganization of the ovaries, closure or dropsy of the Fallopian tubes, and 
recto-vesical or other fistula. 
Treatment.-If the physician is called at the onset of the disease, when 
the chill, pelvic distress, and fever which mark this stage of inflammatory 
transudation indicate the mischief that is threatened, wet cups should be 
immediately applied over the sacro-iliac regions, followed by flaxseed-meal 
poultices as hot as can be borne and large enough to cover the pelvis and the 
lower part of the abdomen. The importance of heat as a means of securing 
the resolution of the inflammation cannot be over-estimated; and its good 
effects can also be realized with peculiar efficacy when it is applied to the 
vagina. To this end a large quantity of warm water should be passed every 
hour or two through this canal, to receive which, as it escapes, a bed-pan 
must be placed under the nates of the patient. The gravity syringe or bag 
is admirably adapted for conveniently employing these douches. 
While these measures are carried into effect, the constitutional disturbance 
must be allayed by a combination of refrigerants and of arterial and nervous 
sedatives, as a tablespoonful every two or three hours of neutral mixture, 
with one drop of the tincture of veratrum viride and one-sixteenth of a grain 
of morphia. When the pain is severe, a suppository of one or two grains of 
opium, oi' the hypodermic administration of a quarter of a grain of morphia, 
will become necessary. The value of these remedies will be greatly enhanced 
by insisting on the most perfect quiet of body and mind. 
The diet during this time should consist chiefly of milk, with light broths. 
If by these measures the acute symptoms are subdued and the disease arrested 
short of suppuration, the next step is to endeavor to get rid of the effused 
serum and lymph. I have not been able to discover at this stage of the 
disease any very marked benefit following the use of those remedies com- 
monly called sorbefacients. I believe the removal of the inflammatory ma- 
terials will be best effected by continuing the use of hot poultices and vaginal 
washes, by hot hip-baths, and by supporting the general strength of the 
patient with tonics and an improved diet, observing to keep the bowels in a 
soluble state by injections of warm flaxseed-tea or water, or by administering 
a teaspoonful of the compound liquorice powder at bedtime. 
When the surgeon finds himself powerless to arrest the progress of the 
inflammation, and suppuration ensues, the duty of supporting the system 
becomes imperative. Accordingly, the diet must consist of such articles as 
will supply abundant nourishment, as beef-essence, milk, milk-punch, eggs, 
etc. Heat, so useful in the other stages of the disease, is not less valuable 
in this, and should be continued, with a view to hasten the maturation of the 
abscess. 
It is now that surgical treatment comes into requisition. The sooner the 
purulent accumulation can be evacuated externally, the better will it be for 
the patient, who during its retention is exposed to septsemic or pyaemic 
infection. And yet it is possible to operate prematurely, before the abscess 
is safely walled up and separated from the surrounding parts, or-before the 
several depots of pus, which often exist, have, through the melting away 
of intermediate barriers, become confluent. When, however, the abscess 
points in a direction accessible to the knife, and the pus is found to be ap- 
proaching the surface, there is no necessity for delay. An opening should 
be made at once, and the contents of the sac evacuated. The manner of tap- 
ping the abscess will be determined by the place where it points. If in the 
vagina, it is best to make the puncture with a sharp-pointed bistoury, while 
the part is exposed to the eye by a Sims speculum. The same course may 
be adopted when the opening is required to be made through the walls of 820 
SURGICAL DISEASES OF WOMEN. 
the rectum. I have sometimes used for this purpose the aspirating trocar, 
guiding the instrument to the proper spot along the finger as a guide. If 
the point of the trocar is kept within the canula until the swelling is reached, 
there will be no risk in its use in this way. It is, however, desirable that the 
opening which becomes necessary should be sufficiently large to allow of the 
constant escape of the pus, and should not close up prematurely : hence the 
bistoury in these cases is preferable to the aspirator. When feasible, the cure 
will be hastened by introducing a drainage-tube into the cavity of the abscess, 
and, by keeping it empty, favoring the contraction of its walls and the ob- 
literation of its cavity. Occasionally the interior of these pyogenic sacs can 
be advantageously treated by injections of permanganate of potash or tinc- 
ture of iodine. 
When a pelvic abscess communicates with the bladder, the fistula can 
often be healed by keeping the bladder empty, cither by the voluntary efforts 
of the patient, or, where these are prejudicial, by the frequent use of the 
catheter. 
Where several sinuses are present, it will often be found that, when their 
course is circuitous, by making the route direct to one the others will close. 
In order to counteract the exhausting effects of a protracted suppuration, it 
will be necessary, in addition to a well-arranged diet, to administer iron, 
quinine, cod-liver oil, and stimulants, and, not the least important, to give 
to the patient the benefit of sea or mountain air. 
Gastro-Hysterotomy, or Caesarean Section. 
Hysterotomy (from the Greek words ucrripa, " uterus," " womb," and ropy, 
" section") is an operation by which the foetus is removed from the uterus by 
incision, either through the abdominal parietes or through the walls of the 
womb. The term is often used in a loose sense, and applied to cases of lapa- 
rotomy in which the foetus is removed from the abdomen either after rupture 
of the uterus or after extra-uterine foetation; or is again improperly em- 
ployed when the child is extruded through the vagina after division of the 
cervix uteri,-vaginal Csesarean section. 
The term " Caesarean section" is thought to have originated in a statement 
made by Pliny with regard to the birth of Caesar, who is said to have been 
taken from his mother's womb by a section of the abdominal walls.* 
If the narrative is true, the operation was attended by the saving of both 
mother and child, as Aurelia was living at the time when the Roman Senate, 
trembling at the successes of the conqueror of Gaul, was maturing plans to 
destroy her son. 
Whether this story is a myth or a fact, no medical writer makes any 
mention of the operation of " hysterotomy" until the time of Guido de Cau- 
lico, who, in the chapter " de extractione foetus," speaks of the propriety of 
removing the latter by abdominal section after the death of the mother; and 
this was also the teaching of Ambrose Pare. 
Churchill states that in Great Britain the first to advise the operation 
while the mother was living was Sir Franklin Ould, in 1742. It is a singular 
fact that, as in the case of lateral lithotomy, tenotomy, and certain other 
operations, Cjesarean section wTas executed first in several parts of the world 
by ignorant and non-professional persons. For example, it is said by Bauhin 
that on the continent of Europe a sow-gelder-Jacques Nuferin-in 1482 de- 
livered his own wife in this manner; in Great Britain the first hysterotomy 
was done by a midwife; in Jamaica by a negro woman on herself, opening 
her side with a butcher-knife; and in the United States also by a young 
negro, or quadroon. 
The first formal hysterotomy in this country was performed, successfully 
as to the life of the mother, in Ohio, in 1827, by Dr. Richmond. A second 
was done by a charlatan in Virginia on a mulatto woman, fatal to both 
Pliny's Natural History, lib. vii. GASTRO-HYSTEROTOMY, OR CAESAREAN SECTION. 
821 
mother and child. A third operation-unsuccessful-was done in Pennsyl- 
vania, in the neighborhood of the town of Northumberland, by Drs. Dougal 
and Van Valzah. A fourth and a fifth were made in Ohio, by Dr. Estep, in 
1833 and 1834, both mothers recovering. In Philadelphia, the operation of 
Caesarean section was first performed by Professor William Gibson, in 1835, 
on Mrs. Reybold, both child and mother surviving. This woman was oper- 
ated on a second time by the same surgeon, and with a like favorable result. 
In 1869, hysterotomy was done by Dr. Walter F. Atlee, the mother dying 
but the child surviving; and in 1880 the operation was twice performed, 
once by the author, unsuccessfully, on a lady five months advanced in preg- 
nancy, labor having come on prematurely, the expulsion of the foetus being 
prevented by the presence in the pelvis of an immovable fibroid, and once 
by Dr. Elliott Richardson on a dwarf at full term, saving both mother and 
child. 
The conditions demanding gastro-hysterotomy are such as arise from 
a deformed state of the pelvis, as in rickets and malacosteon, or from the 
presence of large tumors or exostoses of the pelvic bones obstructing the 
passage of the foetus. 
The late Dr. John Parry, of Philadelphia, in an analysis of 70 cases of 
craniotomy performed in pelves whose conjugate diameters did not exceed 
two and a half inches, the patients having all been under the care of ob- 
stetricians of recognized competency, found the mortality as to the mothers 
amount to 26, or 37t}- per cent.,-a fatality quite as great as that resulting 
from Csesarean section. Dr. Harris, who has studied the subject of gastro- 
hysterotomy critically, comparing cases of craniotomy and hysterotomy 
conducted under like favorable conditions as to operative skill, arrived at 
almost the same result; that is, in 32 cases of Ciesarean section, 20 women 
were saved and 16 children,-a mortality of 371 per cent., against per 
cent, as obtained in Parry's comparative analysis. The advantage in this 
comparison in favor of hysterotomy is obvious, as, though the figures indi- 
cating the death-rate to the mother are nearly alike in both, in the Cajsarean 
operation there is the gain of 16, or 50 per cent., of children. Harris's cases 
of hysterotomy, also, were not selected ones,-that is, operations done early, 
before the patients were exhausted ; and this is important, as delay adds very 
largely to the mortality of the procedure. 
It would thus appear that when the conjugate diameter of the pelvis does 
not exceed two and a half inches, Ceesarean section offers a better prospect 
of recovery than craniotomy. 
There are three modes practiced for the extraction of the foetus through 
the abdominal walls,-the first commonly known as the Caesarean operation, 
the second as the Porro method, and the third styled laparo-elytrotomy. 
Caesarean Operation.-The patient having been etherized and placed on a 
table covered with several thicknesses of comfortables, and her feet resting on 
a chair, the bladder is first to be evacuated. The surgeon then carries an in- 
cision along the median line from the umbilicus to the pubes, dividing care- 
fully the different layers until the peritoneum is reached. After opening the 
latter membrane, the uterus will be brought into view, covered with a net- 
work of enormously-dilated veins. The organ being steadied by the hands 
of an assistant, pressing one on each side of the wound in the abdominal 
parietes, so as to keep the latter in close contact with the womb and thus 
prevent the escape of the intestines, an incision is carried through the 
uterus sufficiently long to admit readily of the extraction of the child and 
the placenta. After both have been removed, any vessels which continue to 
bleed must be tied with the animal thread and all blood carefully sponged 
out of the abdominal and pelvic cavities. On the propriety of closing the 
uterine wound with sutures or leaving the approximation to natural processes 
alone there is a diversity of opinion. Uterine sutures have been used in 19 
cases, three times early, with 2 recoveries, and sixteen times late, with 4 
recoveries. In reviewing the subject from the stand-point of results, where 822 
SURGICAL DISEASES OF WOMEN. 
both plans have been adopted, the question may still be considered as an 
open one. On theoretical grounds I should be in favor of the suture. With- 
out it there is certainly some danger of the lochiae or other uterine discharges 
passing into the peritoneum, or, in the event of the organ not contracting 
properly, of the intestine entering the cavity of the womb. 
The materials which have been used as sutures are silk, catgut, and 
wire. Wells employed silk, and brought them out of the vagina. Simpson 
used iron wire, and Meadows, Viet, Routh, and others have tested catgut, 
or animal thread. Silver wire seems to have answered best. One woman 
was twice operated upon, with an interval of five years, and her uterus 
closed with silver wire on each occasion: she made a good recovery in each 
instance. 
Either silver wire or the carbolized silk or catgut thread will answer for 
the purpose. In each case there is reason to believe that the ligatures be- 
come encysted, though, if brought out through the vagina, they will ulcerate 
into the uterus, as in Mr. Wells's case. The interrupted suture is the form 
best adapted for the closure. To prevent accumulations in the cavity of the 
uterus, a rubber drainage-tube may be introduced into the organ through the 
vagina. In bringing togethei* the abdominal walls the same course is to be 
adopted as in ovariotomy, namely, interrupted silver sutures should be in- 
serted so as to include all the layers of the parietes as well as the reflected 
peritoneum. The external wound, being adjusted, is now covered with car- 
bolized gauze, a sheet of antiseptic cotton-wool laid over the abdomen, and 
the dressing secured by carrying broad strips of adhesive plaster across the 
body, or by surrounding the abdomen with a flannel binder. The subsequent 
management of the case must be the same as after ovariotomy. 
Porro Method.-This differs from the Caesarean operation in this par- 
ticular ; that after the extraction of the child the uterus is extirpated in its 
entirety, leaving the ovaries. In separating the womb from the latter, the 
broad ligaments should be included in double carbolized silk ligatures before 
being divided, and the neck of the organ secured by a clamp before being 
severed from the body. The ligatures are to be cut off close to the knots, 
and the clamp is to be brought out of the external wound. 
The Porro operation, as communicated to me in a letter by I)r. Harris, 
has been done 59 times, saving 22 women, or 37.3 per cent., and 42 children. 
These 59 cases were distributed as follows: 
Country. 
Number of 
Cases. 
Women 
Saved. 
Children 
Saved. 
Italy 
26 
9 
19 
Austria 
11 
7 
11 
France 
8 
4 
5 
Germany 
,.... 
5 
0 
3 
Belgium 
4 
1 
2 
United States 
4 
0 
2 
Switzerland 
1 
1 
0 
- 
- 
Total 
, 
59 
22 
42 
In one of the cases twins were extracted, both of whom died within an 
hour. Chiara and Mangiagalli, at the Santa Catarina Hospital, Milan, saved 
4 women and 6 children in 6 operations; and at the Allgemeine Kranken- 
haus, Vienna, Spath and C. and G. Braun saved 5 women and 9 children. 
Of 122 cases of the Caesarean operation performed in the United States, 
after the old plan, 50, or 41 per cent., recovered; and of 130 cases done in 
North America, 56 recovered,-a success greater than that resulting from 
the Porro method. 
The Caesarean section in Great Britain has proved singularly fatal. By 
reference to Harris's exhaustive paper, it will be seen that in 124 operations 
only 25 women were saved. Of the whole number 68 children were delivered 
alive. In the last twenty years there have been 52 cases of the operation 
and 12 saved, or only 23 per cent. This great mortality cannot, of course, GASTRO-HYSTEROTOMY, OR CAESAREAN SECTION. 
823 
be attributed to any want of skill on the part of the operator, but is most 
probably due to the defective constitutions of the patients. 
An important element in the success of the Ctesarean operation is time. 
Early operations-those, for example, executed within the first twenty-four 
hours, before the powers of the woman have been exhausted by fruitless 
pains-furnish a far more favorable result than those which have been 
delayed to a latex1 period. Thus, we find that in 28 timely operations,-those 
done during the first day of labor,-performed in the United States, 21, or 
75 per cent., recovered; 23 of the children were removed alive, and 19 of 
them saved. In the light of this fact, when the conditions exist which war- 
rant the operation of the Caesarean section there should be prompt action 
as soon as labor has set in. The causes of death in unsuccessful cases of hys- 
terotomy are peritonitis, exhaustion, septaemia, and occasionally convulsions. 
Laparo-Elytrotomy.-In this operation the vagina is opened by making 
an incision above Poupart's ligament through the different layers of the 
abdomen down to the peritoneum, as in the operation for ligating the iliac 
artery. This operation, we learn from Harris, has been performed 9 times: 
4 times in New York, with 2 recoveries; 3 times in Brooklyn, with 2 re- 
coveries ; and twice in England, with 2 deaths; or, in all, 4 recoveries and 5 
deaths,-a success of 44J per cent. 
History.-The suggestion of laparo-elytrotomy was first made in 1806, by 
Joerg, a German obstetrician, who proposed opening the abdomen in the 
median line and incising the vagina from the pelvic side of the canal, and, 
if this was not sufficient for the extraction of the child, prolonging the 
cut through the os and cervix uteri into the body of the organ. Although 
this procedure was never carried into practice, the proposal probably led 
Ritgen, in 1820, to mature a plan for reaching the vagina through the 
abdomen without opening the peritoneum, which he carried into effect in 
1821, though the operator, on account of hemorrhage, wras compelled to 
resort to hysterotomy for the removal of the foetus before terminating the 
operation. 
In 1824, Louis Auguste Baudelocque, a nephew of the distinguished ob- 
stetrician Baudelocque, supposing that this method was original with him- 
self, published a paper on the subject which contained the history of two 
operations of the kind. In one it was found necessary to supplement the 
Ciesarean section of the womb, as in Ritgen's case, on account of hemor- 
rhage ; and in the other, although the child was delivered through the open- 
ing made into the vagina, it was not accomplished without wounding the 
external iliac artery and requiring the ligature of the primitive iliac vessel. 
In all of these cases a fatal termination ensued. 
It appears from a letter of Dr. Horner's, written in 1824, before these 
operations of Baudelocque, that Dr. Physick had suggested the same method 
as a substitute for the Caesarean section. In 1837, Sir Charles Bell advo- 
cated a similar plan, which is described in his treatise on surgery. As with 
many other methods in surgery, the subject appears to have been lost sight 
of for a time, until, in 1870, Dr. Thomas revived the operation by reporting 
two successful cases. These were followed by the cases of Dr. Skene, who 
thrice made the operation of elytrotomy; and finally Dr. Gillette extracted 
a foetus by the same method without inflicting any damage on the bladder. 
Operation.-An incision is made one inch above and parallel with Pou- 
part's ligament, commencing at the external abdominal ring, and extending 
to a point nearly opposite the anterior spinous process of the ilium. The 
layers of the abdominal walls, consisting of the integument, tendon of the 
external oblique, internal oblique, and transvcrsalis muscles, are next raised 
and divided on a director until the transversalis fascia is reached. This 
structure must now be torn, and the peritoneum immediately beneath pushed 
upward without being opened. The cavity of the pelvis being exposed, a 
sound is passed into the vagina, and the wall of the canal made prominent, 
into which a small opening is made, which is enlarged by tearing with the 824 
SURGICAL DISEASES OF WOMEN. 
fingers as nearly as possible in a longitudinal direction, or in the long axis 
of the canal, the object being to avoid hemorrhage. It has been suggested 
that, in order to prevent bleeding, the opening into the vagina should be 
made with the galvano-cautery. The thermo-cautery of Paquelin would 
answer equally well. 
The foetus, having descended, is now to be seized and brought through the 
opening, after which the placenta should be extracted. All hemorrhage being 
controlled, and the pelvis carefully sponged dry, the approximation of the 
external wound is to be made in the same manner as after ligature of the 
iliac arteries, an operation very similar in its earlier stages to that of ely- 
trotomy. Thomas advocates the use of a drainage-tube, allowing one end to 
extend into the pelvis, and the other to protrude through the lower angle of 
the external wound. 
The danger to the ureters and the bladder when enlarging the wound in 
the vagina is unquestionably great, a fact which suggests the importance of 
entering the canal close to the side of the pelvis. In considering the acci- 
dents which have occurred to operators in performing elytrotomy, with the 
damage which is likely to be inflicted on the ureters, bladder, and vessels of 
the pelvis, it is apparent that more than common skill is demanded for the 
propei* execution of the task of removing a foetus by the method described,- 
so much more, indeed, than that required in the Caesarean section that it is 
very improbable that it will ever supplant the latter. 
Through the invaluable labors of Dr. Harris, conducted under difficulties 
which I am sure would have discouraged any ordinary investigator, we are 
in possession of the records of 374 cases of gastro-hysterotomy, or Caesarean 
section, distributed as follows: 
In America, 130; in the United States, 122; in the United Kingdom of 
Great Britain and Ireland, 122. Of the whole number, 131 women (35 per 
cent.) recovered and 243 died; and of the children, 134 were saved. 
Twelve hundred and eighty-five cases of the Caesarean operation in Conti- 
nental Europe have been reported, but so indefinitely that it is at present 
impossible to make any reliable analysis of them. 
The records of the operation and its results in North America and in the 
United States, deducible from the data of the same author, are as follows: 
In North America there have been 122 Caesarean operations, 56 of the 
women being saved, or about 46 per cent. In the United States there have 
been 113 Caesarean operations, 49 of the women being saved, or 43 per 
cent. 
The published cases in the United States amount to 65; the unpublished 
cases to 57. Of the published cases there were saved 36 women, or 55.4 per 
cent. Of the unpublished cases there were saved 13 women, or 22.8 per 
cent. In 28 instances the operations were done on the first day of labor; 
14 of the patients were white, and 14 black; 11 whites and 10 blacks re- 
covered,-21, or 75 per cent.; 23 children were removed alive, and 19 of 
them saved. 
In North America, 9 women-1 whites and 5 blacks-were operated on 
twice each, 8 of the 9 being in the United States; 2 of the blacks died after 
the second operation, one of them having been pregnant five months and 
suffering at the time from dysentery, and the other from having her ovaries 
removed at the request of her owner. Eight of the second operations were 
performed by the same operators as in the first instance. In the case just 
mentioned, which was complicated by the removal of the ovaries, the operator 
had not performed the first operation. Of the children, 14 of the 18 were 
saved. Two of the white women, with their children, are still living. One 
woman is seventy-one and the othei* thirty-four. The first has six grand- 
children. 
In all of the 122 operations the uterus as well as the abdomen was incised: 
consequently all cases in which gastrotomy was performed for the extraction 
of a foetus which had escaped into the abdomen through a laceration in URETHRITIS. 
825 
the walls of the uterus have been excluded from the above collection as not 
properly belonging to the Caesarean operation. 
Of 24 dwarfs,-17 white and 7 black,-only 7 recovered; 5 of the 7 were 
operated upon early. These dwarfs measured from three feet two inches to 
four feet eight inches in height. 
Of 17 cases operated upon late, only 2 recovered. 
DISEASES AND INJURIES OF THE URETHRA AND BLADDER. 
Diseases and Injuries of the Urethra. 
Congenital vices of the urethra are not common. The canal may be absent 
or cleft. 
Absence of the Urethra.-In cases of this nature there is a deep depression 
beneath the arch of the pubes, at the bottom of which is seen the open mouth 
of the bladder. It may be desirable under such circumstances to construct 
a canal so as to convey the urine to the anterior surface of the vulva. Em- 
mett, in a case of this kind, accomplished the object by raising two flaps 
of mucous membrane, one on either side of the median line, and suturing 
together their raw surfaces by interrupted silver sutures. 
Lacerations of the Urethra are sometimes inflicted by falls upon pointed 
bodies, and are to be treated by closing the laceration over a catheter with 
interrupted silver sutures. The catheter should be retained in the bladder 
for four days, or until union has taken place, at which time the stitches 
should be removed. 
Sloughing of the urethra has resulted from phagedsenic ulceration of the 
vagina, but more frequently from the long-continued pressure of the foetal 
head in protracted labors. 
When the destruction is not too great, the canal can be reformed by fresh- 
ening the margins of the opening, and, as in laceration, bringing the sides 
together over a catheter, the latter being worn until the union is complete. 
Should the loss of substance be too great to permit this, it will be necessary 
to secure two flaps by making a longitudinal incision on either side some dis- 
tance from the remains of the canal, and, after turning their mucous surfaces 
inward, unite the margins of the flaps over a catheter by interrupted sutures. 
Obliteration of the Urethra, the result of inflammatory destruction of the 
mucous membrane, is occasionally witnessed. In one case which came under 
my care it was associated with a vesico-vaginal fistula, both being produced 
by the same cause. I first reformed the canal by tunneling the cicatricial 
tissue which occupied its centre or axis by a trocar, and secured its patulous 
condition by passing bougies daily until the surface healed. The fistula was 
afterwards closed. 
Urethritis.-Inflammation of the urethra occasionally follows a vaginitis, 
or it may be caused by the rude use of instruments. The disease may be 
recognized by the extreme red color of the mucous membrane, the swollen 
condition of the meatus, and the vesical tenesmus and burning, scalding 
sensation accompanying urination. It is important that the disease should 
be arrested as early as possible, since otherwise the inflammation tends to 
creep upward into the bladder and give rise to a serious cystitis. 
Treatment.-When the urethritis is caused by an extension of gonorrhoeal 
inflammation, our efforts must be directed to the cure of the latter disease, 
without which all remedies addressed to the urethra alone will prove valueless. 
With a view to remove the urethritis, the topical application of hot water 
frequently to the vulva and the use of weak urethral injections of the sul- 826 
SURGICAL DISEASES OF WOMEN. 
phate of zinc (zinci sulph., gr. i to gr. iij; aqua rosse, 30 or of the nitrate 
of silver (argenti nitras, gr. } to i; aqua destillat., §i) constitute the most 
efficient remedies, together with the free use of alkaline diluents in order to 
render the urine as unirritating as possible. 
Granular Urethritis.-The condition which I term granular urethritis con- 
sists in a hypertrophied state of the papillae of the mucous membrane of the 
urethra, and is commonly met with in females over thirty years of age who 
have borne children. It is attended with an irritable state of the bladder, 
the patient complaining of a sense of fullness at the neck of the organ, 
with vesical tenesmus and extreme ardor urinae. On examining the urethra, 
the mucous membrane is found sensitive, somewhat redder than natural, and 
studded with numerous fleshy eminences. 
At one time I was led to believe that nothing short of cauterization by 
strong mineral acids would avail for the cure of the disease; but a larger ex- 
perience has taught me that the persistent daily use of graduated bougies, 
well smeared with an ointment consisting of ten grains of tannic acid, three 
grains of sulphate of morphia, and three drachms of cold cream, will remove 
the irritation and restore the mucous membrane to its healthy condition. 
With a little instruction the woman can herself use the instrument. 
Tumors.-There are two kinds of tumors which arise in the course of the 
urethra, the polypoid and the neuro-vascular. 
Polypoid growths are to be considered as fibromata or fibro-adenomata. 
They are pedunculated, pyriform in shape, and have their attachment near 
the mouth of the bladder. They consist almost entirely of delicate threads 
of connective tissue. 
These growths give rise to severe local irritation, occasioning a constant 
desire to urinate, attended with pain, and frequently offer considerable ob- 
struction to the flow of water. From the position which they occupy in 
the urethra, the true character of the disease is often overlooked. The only 
positive evidence of the existence of a polypoid growth in the urethra is that 
furnished by the sight; and hence, when investigating a case in which the 
presence of such a neoplasm is suspected, the interior of the canal must be 
exposed by the dilating forceps. 
In removing a urethral polypus the growth should be seized by a pair of 
forceps and its pedicle put upon the stretch, when it may be severed from 
its attachment to the walls of the canal, either by long, narrow-bladed 
scissors, or with the dressing-forceps. 
Fibro-vascular tumors, or urethral hemorrhoids, are much more common than 
the polypoid. Though seen at all periods of life, they are most frequently 
met with in young females. The part of the urethra from which they grow 
is near the meatus, and consequently they are easy of detection. The tumor 
lies in or protrudes from the orifice of the urethra, possesses an intensely 
red color, and is about the size of a pea, its surface being often granular and 
exceedingly sensitive to the touch. These vascular growths have a sessile 
base, and frequently bear a strong resemblance to a red raspberry. The 
irritation, suffering, and vesical tenesmus and distress which attend their 
presence are quite sufficient in many instances to incapacitate the patient 
from attending to any duties whatever. 
These growths are constituted of fine nerve-filaments and blood-vessels, 
supported on a framework of delicate connective tissue. The blood-vessels 
are sometimes so numerous as to give to the tumor an erectile character. 
The treatment is very simple, and radical in its result. I have removed very 
many such growths, and have never once witnessed their recurrence. 
A tenaculum being passed through the tumor, it is to be drawn well 
out of the meatus and clipped off with a pair of scissors close to the surface 
from which it grows. As soon as the bleeding subsides, the site from which 
the growth has been cut away must be touched with either pure nitric acid CHRONIC CYSTITIS. 
827 
or acid nitrate of mercury, care being taking to neutralize the redundant 
fluid by injecting into the urethra a solution of nitrate of potash or some 
sweet oil. 
Urethrocele. 
This term is applied to two different conditions,-one in which there is a 
prolapse of the redundant and thickened tissues of the urethra external to 
its canal, and another in which there is a protrusion of its mucous mem- 
brane, forming a red, congested, and spongy mass external to the meatus. 
Frequently the prolapsed membrane belongs rather to the bladder than to 
the urethra. The effect of the protrusion is to dilate the canal, and yet 
the retentive power of the neck of the bladder is not materially impaired. 
A woman in one of my wards at the Pennsylvania Hospital was admitted 
on account of a urethrocele which had expanded the passage to a degree 
which easily admitted the finger into the bladder, and yet there was no 
complaint of incontinence of urine. In these cases the roll of mucous mem- 
brane doubtless forms a stopper for the mouth of the bladder. 
Causes.-The causes concerned in producing this affection are all those 
which create straining or tenesmus of the bladder, as cystitis, cystocele, 
tumors of the urethra, hemorrhoids, pelvic cellulitis, etc. 
Treatment.-In that form of urethrocele in which there is an excess of 
peri-urethral tissue, and where the symptoms are sufficiently severe to justify 
operative measures, the plan adopted for the cure of cystocele, though on a 
less extensive scale, will be proper. 
It is important, before any operation, to remove as far as possible every 
cause which may be concerned in the production of the urethrocele. After 
this, when the prolapse is confined to the mucous membrane, the operation 
must be determined by the extent of the mucous membrane involved. If the 
disease is limited to that portion neai' the meatus and only slightly affects 
the membrane, either on one aspect of the canal or around its entire circum- 
ference, unless the local irritation is particularly annoying it will be better 
not to meddle in the case at all. If, however, the symptoms are urgent, the 
prolapsed portion may be raised by a tenaculum and cut away. 
When the redundant tissue extends all the way round the orifice of the 
canal, if division alone is employed, the prolapsed membrane must be raised 
about the urethral orifice and the folds excised at two or three places, in a 
direction answering to the long axis of the canal. Should, however, the mass 
be voluminous, it will be better to include it in one or more double or single 
ligatures, and, after tightening the threads firmly, to cut off the strangulated 
membrane near the ligatures. 
When the prolapsed portion is derived from the circumference of the 
urethra higher up, and refuses to remain in place after reduction, a very 
ingenious operation has been practiced by Dr. Emmett, which consists in 
making a longitudinal slit through the walls of the urethra down to the 
mucous membrane, then drawing the redundant portion of the latter through 
the opening, and, after introducing a sound into the canal in order to smooth 
out its lining membrane, passing a sufficient number of interrupted sutures 
through the sides of the wound, including the mucous membrane, after which 
the latter is cut off and the stitches tied. 
The same operation will be proper when the prolapsed membrane is 
derived from the bladder. When the cystocele is the result of a cystitis, all 
retrenchment of the mucous membrane by operation will be useless, unless 
the disease of the bladder can be removed, and, with the latter object in view, 
it may be necessary to establish a vesico-vaginal fistula. 
Chronic Cystitis is less common in the female than in the male, but quite 
as rebellious to treatment. 
Causes.-Among the causes which are concerned in developing cystitis in 
the female are vesical calculi, polypi and papillomata in the viscus, displace- 828 
SURGICAL DISEASES OF WOMEN. 
mcnts of the uterus, retention of urine, cold, reflected irritation from the 
rectum, as in ulceration, hemorrhoids, or fissure of the bowel, accidents during 
labor, and exposure to cold. Indeed, any long-continued irritation of the 
bladder predisposes the patient to the development of cystitis, simply because 
the alteration in the form of the bas-fond of the organ and the turgescence oi' 
hypertrophy of the mucous membrane at its neck, which follow frequently- 
repeated straining in efforts at micturition, tend to offer an obstacle to the 
complete expulsion of the urine, so that a portion remaining and undergoing 
decomposition becomes a direct cause of inflammation. As in chronic cystitis 
of the male, so in that of the female, the ureters and kidneys are prone to 
organic changes. The symptoms which characterize the disease are much 
alike in both sexes. 
Treatment.-It is of the first importance, in taking charge of a case of 
cystitis, to institute a careful inquiry, with a view to discover if there exists 
any cause which is likely to perpetuate the disease, and, when possible, to 
remove the same. Thus, fissure of the anus, hemorrhoids, vesical or urethral 
growths, and displacements of the womb, are all irritants calculated to sus- 
tain inflammation of the bladder, and, being all correctible, ought to be elimi- 
nated from the case by timely operations and by instrumental supports. In 
this wTay much relief will be obtained by withdrawing a certain amount of 
irritation from the bladder. Nevertheless, there will still remain enough in 
many instances to render the woman, by the incessant worry, smarting, 
pain, straining, and constantly-repeated efforts at urination, one of the most 
miserable of human beings. 
Injections of warm water, of nitrate of silver, and many other agents, ad- 
vocated by some authorities, I am compelled to say, in my experience, have 
been as valueless as when introduced into the male bladder. Not so, however, 
with catheterization, which in the early and indeed throughout all stages of 
the cystitis should be practiced twice daily, so as to insure the removal of all 
sedimentary depositions which are not expelled by the voluntary efforts of 
the patient. 
The free use of diluents will also be required to diminish the irritation of 
the urine. As the latter from its chemical constitution tends to aggravate 
the local inflammation, it has been thought that by providing for its escape, 
and thus securing repose to the vesical walls, a cure would be effected. On 
this supposition is based the operation of cystotomy, a surgical procedure 
suggested by Professor Willard Parker, of New York, in 1850. 
The operation is done by placing the woman on the side, expanding the 
vagina with a Sims speculum, and, raising the vesico-vaginal wall immediately 
behind the neck of the bladder with a tenaculum, excising in a transverse 
direction an elliptical piece of the septum. The division of the anterior wall 
of the vagina will be facilitated by causing it to be somewhat raised on the 
point of a metal catheter passed into the bladder. In this way a fistula is 
established, through ■which the urine passes into the vagina, and which, 
although a source of annoyance to the patient, is much more bearable than 
the suffering that it alleviates. The operation, however, in well-established 
cases of chronic cystitis, is only palliative. 
To prevent the opening from becoming too small and contracted, various 
plans have been advocated. Emmett recommends a glass stud to be inserted ; 
lead will answer equally well for constructing this contrivance. Pallen has 
suggested the thermo-cautery of Paquelin, with which to destroy the vesico- 
vaginal partition ; and Bozeman, with the same object in view, cuts out a 
circular piece. The elliptical opening, which resembles the usual form of 
accidental vesico-vaginal fistula, answers the purpose quite well. 
Irritable Bladder.-This is a very common affection in females, particularly 
among the higher class of patients. It is characterized by very much the 
same phenomena as those belonging to cystitis, except that in the former the 
microscope reveals no pus, ropy mucus, or blood-corpuscles in the urine. Nor EXTRA-UTERINE PREGNANCY. 
829 
does the irritation appear to affect materially the general health. Women 
having an exalted nervous organization, who indulge freely at the table, or 
who suffer from the depressing effects of grief, are those most prone to this 
affection. 
Treatment.-Too often this irritability is referred exclusively to psychical 
causes, and allowed to pass into the more serious condition of cystitis before 
the true nature of the malady is recognized. It will be found in a goodly 
proportion of cases that the irritability has indeed a physical and not an 
imaginary basis; and hence the wisdom of closely interrogating every organ 
which, from its relation to the bladder, might be suspected of creating trouble, 
and of inquiring into the habits of the patient. In this inquiry will be con- 
sidered the possibility of uterine displacements, urethral and vesical growths, 
calculus, anal fissure, hemorrhoids, composition of the urine, and diet. If in 
any of the above particulars the patient is at fault, the correction of the 
defect is of the first importance. Should no such explanation exist for the 
irritability, the case may be regarded as a neurosis, having its origin in an 
anfemic state of the system, or in that exhaustion which is induced by pro- 
tracted anxiety, grief, loss of rest, etc. 
Under these circumstances the blood must be enriched by iron, strychnia, 
quinine, a generous diet, and sea or mountain air. Hot, sometimes cold, hip- 
baths, with suppositories of opium and belladonna, will allay much of the 
irritability, and procure rest at night. Bromide of potassium will also be 
found useful in. effecting the same objects. The patient should be urged to 
lengthen the period (by a few moments) between each succeeding urination. 
By this plan alone I have succeeded in rendering the bladder entirely 
tolerant of the presence of its secretion. 
Forcibly dilating the urethra and the neck of the bladder has been a pop- 
ular practice in cases of irritable bladder, and I have frequently adopted 
this measure when no sufficient cause of the vesical affection could be dis- 
covered. The results, however, have been so unsatisfactory that I attach 
very little importance to the procedure. 
Extra-Uterine Pregnancy. 
An ovum which, after being impregnated, fails to reach the cavity of the 
uterus, its development being continued outside of that organ, constitutes 
what is termed an extra-uterine pregnancy. 
Causes.-The causes which operate to produce extra-uterine foetation are 
such as disturb the true relation between the uterus and its appendages, or 
in any way induce changes in the form or patency of the oviduct calculated 
to offer a mechanical barrier to the migration of the ovum. Among these 
are pelvic or peri-uterine cellulitis, blows over the abdomen at or about 
the period of fecundation, tumors pressing against the Fallopian tube, and 
uterine displacements. In a few instances it has occurred in a hernia of the 
ovary. Some writers, and among them Astruc, Ramsbotham, Baudelocque, 
and Cazeaux, recognize emotional and moral causes among others, as fear, 
super-excitement, etc., growing out of illicit sexual indulgence; in confirma- 
tion of which Chavasse asserts that irregular foetations are more common 
in single than in married women,-a statement, however, which is not sus- 
tained by the observation of other writers. 
It has been noted, especially by Schroeder, that extra-uterine pregnancy is 
usually preceded by a period of sterility; that is, when it occurs in primip- 
aree, a considerable time has elapsed between marriage and the accident; 
and when it happens in multiparse, it has succeeded a previous normal preg- 
nancy after an unusual interval of sterility. 
Women who have borne children suffer more frequently than primiparse. 
Thus, in 500 cases examined by Parry, the number of the pregnancy is 
mentioned in 351, and of these 279 were multiparse and 72 primiparse. 830 
SURGICAL DISEASES OF WOMEN. 
The period of life at "which the accident is most common is between twenty 
and thirty years of age. 
Occasionally there is seen both a normal and an extra-uterine pregnancy 
existing at the same time. This occurs in about 4 in every 100 instances of 
extra-uterine foetation. Gordon* met with a case in which a woman gave 
birth to five children while carrying an extra-uterine foetus. 
There are three localities in which the impregnated ovum may develop: 
in the Fallopian tube,-tubal; in the ovary,-ovarian; and in the abdomen, 
ventral. 
The particular portion of the oviduct in which the ovum becomes arrested 
and grows varies in different cases. It may be where the tube enters the 
uterus, the walls of the latter becoming expanded over the product of 
the pregnancy, sometimes called interstitial extra-uterine foetation, or the 
utero-tubal of Blundell; or it may be at any point between this and the 
ovary. 
While all writers are agreed as to the existence of tubal pregnancy, there 
is considerable diversity of opinion in regard both to ovarian and to ventral 
pregnancy. The occasional existence of both, I think, may be admitted; 
though with reference to the latter it is highly probable that ventral foeta- 
tion is in most instances a secondary result, due to a rupture of a cyst 
primarily occupying the oviduct or the ovary. 
Another interesting subject is the nature of the connection subsisting 
between the misplaced foetus and the circulation of the mother. There is 
no deciduous membrane interspersed between the maternal tissues and the 
radicles of the chorion. 
It would appear from the microscopical examination of Braxton Hicks 
that a plastic deposition takes place on the surface of the membrane with 
which the ovule is in contact, and that the villi of the chorion become im- 
bedded in this material, the connection, through the subsequent formation of 
blood-vessels, becoming a vascular and vital one. 
Though the cyst inclosing an abnormal foetation, it is believed, is devoid 
of a decidua, this structure is always formed in the uterus in cases of extra- 
uterine pregnancy, as though the organ was waiting for the reception of 
the detained or misplaced conception. The membrane, however, does not 
remain until the termination of the gestation, but becomes detached, and is 
expelled from the uterine cavity in fragments,-a fact of some diagnostic 
importance. Should a foetus thus holding a parasitic life survive until the 
full term of utero-gestation, it does not, as a rule, materially differ in the 
perfection of its development from one which has occupied the cavity of the 
uterus. 
The sex of extra-uterine children is almost equally divided between males 
and females. 
Progress and Termination.-The wall or cyst which incloses the foetus, 
especially in cases of tubal pregnancy, very often ruptures before the fourth 
month, allowing its contents to escape and destroying the mother from 
hemorrhage. Out of 329 deaths from extra-uterine pregnancy, 174, or 52.88 
per cent., were due to rupture of the sac. When the above period has been 
passed safely, gestation will probably advance to full term. After the death 
of the foetus it is subject to various changes. It may remain quiescent for an 
indefinite time. In Nebel'sf case the patient, who lived over ninety years, 
had carried the misplaced foetus for fifty-five years; others have been re- 
tained from five to twenty years. Goodell operated on a woman at the 
University Hospital in whom abnormal pregnancy had occurred two years 
previously. The cyst in this case had become adherent to the anterior 
abdominal wall, and was quite resonant at the time of the operation from 
the gases eliminated from the decomposing foetus. Another change is one 
in which the contents of the sac are converted into a substance like adipocere, 
® Western Journal of Medicine and Surgery, October, 1848: Parry, 
t Parry on Extra-Uterine Pregnancy, p. 123. EXTRA- UTERINE PREGNANCY. 
831 
the cyst-wall also undergoing a calcareous transformation, after which both 
may remain harmlessly attached to the body; or the sac may open into the 
intestine, penetrating the sigmoid flexure of the colon, or into the rectum, 
the bladder, or the vagina, or occasionally through the abdominal walls. The 
late Professor John T. Darby met with a case in which an opening existed 
between the sac and the stomach. Dr. Matteii* has given the terminations 
of 100 cases of extra-uterine pregnancies left to nature: 12 of the women, 
after retaining the conception for several years, died suddenly; 5 died from 
accidents during the pregnancy without the cyst opening externally. In 37 
of these cases an opening was made into the cyst through the abdominal 
walls; in 21 this occurred spontaneously, of which number 20 recovered ; in 7 
as a result of operative interference, all recovering; and in 9 by gastrotomy, 
all recovering. In 8 cases the cyst opened into the bladder, 2 proving fatal; 
in 7 it opened spontaneously into the vagina, proving fatal in 2 ; and in 5 the 
opening was made by the surgeon, followed by 4 recoveries. 
Thirty-one of these pregnancies were discharged into the intestinal canal, 
either spontaneously or by operative interference; 12 of the women recovered 
and 19 died. 
The conclusions which Matteii arrives at from the analysis of his collection 
are-first, that old extra-uterine pregnancies allow of life being prolonged 
for many years; they amount to about twelve per cent, of the whole number 
of such foetations, and are likely to become old when the foetus dies early 
and the cyst remains of a small size; secondly, in five per cent, they become 
the cause of death without the cyst opening externally or into a mucous 
canal; thirdly, in one-third of the cases the cyst, whether opened or not, 
is expelled ; and, fourthly, in twenty-eight per cent, the opening, whether 
spontaneous or artificial, takes place through the abdomen. The analyses 
of Pusch and Parry do not materially alter the conclusions of Matteii. 
Among the first symptoms which are likely to attract special attention is 
a one-sided pain, occurring towards the end of the first month of the preg- 
nancy, located deep in the hypogastric or the iliac region, and often suf- 
ficiently severe to produce alarming prostration. The pain, which rarely 
continues over twenty-four hours, is replaced by marked tenderness on press- 
ure. These attacks are likely to be repeated at intervals ranging from 
several days to weeks, and are the effect of nerve-pressure, from the un- 
willingness with wThich the structures inclosing the foetus yield. To the 
above symptoms may be added a bloody discharge from the vagina, caused 
either by the separation of the decidua or by the rupture of some of the 
uterine or tubal vessels from over-distention or engorgement. 
A case of suspected pregnancy, with such symptoms, ought to suggest the 
necessity of making a vaginal examination, as the uterus does not remain 
quiescent, but increases in size in cases of abnormal pregnancy much in the 
same manner as when the product of conception occupies its cavity. 
The vaginal examination may result in the detection of the foetus in its 
erratic position. Noeggerath advises that when other measures of explora- 
tion fail, and the grounds for believing in the existence of an abnormal foeta- 
tion are plausible, the examination be made by the finger introduced through 
the urethra into the bladder, which renders both the uterine and the ovarian 
regions very accessible to the touch. In the more advanced stage of the 
pregnancy still more decisive signs appear, as the movements of the child 
and the sound of the foetal heart. Of course these phenomena establish only 
the fact of pregnancy, without reference to its kind. Often, however, it is 
possible to trace the outline of certain portions of the foetus through the ab- 
dominal walls, and an examination made through the vagina may discover 
not only a tumor behind the uterus, but also the outlines of a part of the 
child; conjoined manipulation may at the same time reveal the independent 
mobility of the latter, and, possibly, its displacement to one side. 
Too much importance must not be attached to the knowledge gained by 
* Medical Times and Gazette, 1861, vol. ii. p. 172. 832 
SURGICAL DISEASES OF WOMEN. 
an external exploration of the abdomen. In a case which I saw with Dr. 
Stewart of this city, and which was supposed to be one of extra-uterine 
pregnancy, the configuration of a foetus could be distinctly traced through 
the parietes, and yet, as the result showed, the child was in utero. The in- 
troduction of a sound into the uterus would of course determine if its cavity 
was unoccupied; but in the event of the opposite condition being the case, 
premature labor would almost certainly follow. The usual enlargement of 
the mammae, and the sickness belonging to ordinary pregnancy, are not 
wanting in cases of extra-uterine fcetation. 
When the foetus is carried to the full term, labor-pains set in as in an ordi- 
nary case of mature utero-gestation. 
Diagnosis.-The diagnosis of extra-uterine pregnancy must be admitted 
to be very difficult. Errors have been committed in such cases by men of 
acknowledged ability. Dieffenbach, in a supposed case of extra-uterine preg- 
nancy, made the abdominal section, when it was found that no pregnancy of 
any kind existed. The surgeon, therefore, should proceed with the utmost 
caution, and not enter on an operation of so serious a nature as that of 
opening the abdomen until he is in possession of the most conclusive evidence 
that the gestation is abnormal. The earlier the true nature of the case is 
recognized, the better for the patient. The great fatality attending the most 
common form of these pregnancies, namely, the tubal, from rupture of the 
oviduct, will impart force to this statement. 
In attempting, therefore, to make an early diagnosis, the general fact of a 
pregnancy must first be ascertained, and next any circumstances connected 
with the condition which may be deemed unusual or irregular to normal 
gestation. It has been shown that, so far as authors on this subject have been 
able to gather information, women who have been the subjects of extra- 
uterine fcetation have generally been conscious of something peculiar in the 
signs betokening pregnancy, or, if multiparae, have noticed symptoms which 
were altogether different from those which attended previous gestations. 
For example, the pains have been of unwonted severity, and located in the 
hypogastric or the iliac region; the exhaustion has partaken more of the char- 
acter of shock or collapse than of prostration incident to mere nervous per- 
turbation. It is impossible, indeed, for a patient to sink down in a state of 
syncope, with a pallid face, pinched features, cold extremities, and skin bathed 
in clammy perspiration, unless something unnatural and grave has occurred. 
If in addition to these signs there has been a bloody discharge from the 
uterus, or the fragmentary expulsion of the decidua, there is the strongest 
ground for suspecting an extra-uterine pregnancy. 
Later on in the history of the accident corroborative evidence of the preg- 
nancy can be obtained by vaginal examination, simple or conjoined with ab- 
dominal pressure, the patient being under ether; that is, a tumor can be 
felt by the touch, laterally or posteriorly, located in the pelvis; possibly the 
outline of a limb may be distinguished; and if the foetus has reached the 
fourth month the very decisive test of ballottement can be employed, also 
the exploration through the bladder, as suggested by Noeggerath. 
In cases which have advanced to a still later period the physician may 
have not only the phenomena already described to guide his inquiry, but 
also those of the sound of the foetal heart and an empty uterus, the size 
of which is altogether disproportioned to the magnitude of the abdominal 
tumor. 
Extra-uterine pregnancy may be confounded with pelvic cellulitis, bsema- 
tocele, fibroid tumors, and other tumors of the uterus. 
Pelvic cellulitis. - I once committed the error of confounding a case of 
extra-uterine pregnancy with this affection. The points of resemblance be- 
tween extra-uterine fcetation and pelvic cellulitis are tenderness at the dome 
of the vagina, sometimes paroxysmal pain, an induration often more or less 
circumscribed, and a certain degree of uterine fixation. The points of dis- 
similarity are the conviction of the patient that she is pregnant, the extraor- EXTRA-UTERINE PREGNANCY. 
833 
dinary pain, the violent constitutional manifestations, and the discharge of 
blood from the womb, phenomena which belong to extra-uterine pregnancy. 
Pelvic hcematocele is not necessarily associated with a previous history of 
pregnancy, is a diffused tense swelling, and either forms an enlargement on 
all sides of the uterus, if of the peritoneal variety, or, when infra-peritoneal, 
compresses the rectum and the bladder, none of which symptoms attend 
extra-uterine pregnancy. 
Uterine, or ovarian tumors.-Meadows, of London, once opened the ab- 
domen in a woman having a tumor supposed to be an abnormal pregnancy, 
but which turned out to be a fibroma. Tumors within the pelvis, whether 
connected with the uterus or with the ovaries, are not marked by any acute or 
violent symptoms, such as have been described as belonging to the initial stage 
of extra-uterine fcetation, and, except when within the cavity or walls, are not 
accompanied by any increase in the depth of the uterine cavity, or by any 
of those changes of the os or cervix, as softness or sponginess, which mark 
pregnancy. 
In uterine fibromata there is also an absence of independent movement be- 
tween the organ and the growth, as change in the position of the one neces- 
sarily affects the other. Fibroids, again, are hard and generally irregular 
tumors. As the above characteristics are unlike any which belong to extra- 
uterine pregnancy, it is not probable that a mistake will be made by con- 
founding the latter with the former, where the usual care is bestowed in the 
investigation. 
Aside from other signs, fluctuation and the aspirating trocar will establish 
the distinction between abnormal pregnancy and ovarian and other cysts 
connected with the appendages of the uterus. A malignant growth within 
the abdomen has been mistaken for an extra-uterine fcetation. Here, again, 
the early history of the latter must be recalled,-in every way unlike that 
of carcinoma, which generally progresses slowly, is attended with disorders 
of the digestive apparatus, is accompanied by a loss of flesh, and finally 
impresses on the face of the patient the lineaments of an unmistakable 
cachexia. 
Treatment.-When an extra-uterine fcetation has been early discovered, 
it has been proposed to destroy the ovum, either indirectly through the 
system of the mother, or directly, by acting immediately on the cyst. 
The administration of ergot and of strychnia, and profuse bleedings, have 
been suggested with the first object in view, but do not merit serious con- 
sideration. 
The second method has been attempted in different ways. First, the sac- 
has been punctured through the vagina and the amniotic fluid drawn off. The 
operation, however, has been very unsuccessful. Sir James Simpson prac- 
ticed it in one instance, but lost his patient. A similar result followed a like 
operation in my own hands. It has been repeated six or seven times, and 
always with a fatal termination, except in a single case,-that of Green- 
halgh. Second, the sac has been opened by Professor Thomas through the 
vagina, by the galvano-cautery, and the embryo extracted. Third, attempts 
have been made to destroy the foetus by electricity. Dr. Jonathan Allen 
succeeded in two instances in accomplishing this by electro-magnetism, one 
pole being placed on the swelling in the vagina and the other over the 
hypogastrium. 
Other methods have been proposed, but with so little prospect of effecting 
any good result that they need not be rehearsed. It is proper to notice, 
before leaving this subject, the proposition of Joulin, to destroy the embryo 
by injections into the sac, and which, in the hands of Koeberle, proved suc- 
cessful in one case. The agent which he used was the hydrochlorate of 
morphia. 
The results of the different operations on the sac, made with the view of 
destroying the foetus, are not encouraging. Most of these procedures have 
been fatal to the mother, which alone is a sufficient reason for their con- 
vol. ii.-53 834 
SURGICAL DISEASES OU WOMEN. 
demnation. The foetus, if allowed to remain quiescent in the sac, may arrive 
at a viable age, or may undergo those chemical transformations which trans- 
mute its tissues into a harmless mass of adipocere, or into some cretaceous 
substance. 
Removal of the Foetus per Vaginam.-In 1756, Dr. Charles Kelly suggested 
the extraction of the products of an extra-uterine conception by making 
an opening through the vagina into Douglas's cul-de sac, much in the same 
manner as is done in vaginal ovariotomy. This operation is not a difficult 
one, but should be confined to cases in which the foetus can be clearly recog- 
nized as pressing into the vagina at a viable age, or after its death. 
Operation.-The rectum and bladder being emptied, the woman, pre- 
viously etherized, is to be placed on her back, with the hips projecting over 
the side of the bed, and with the limbs separated and flexed on the abdomen, 
each being supported by an assistant. The vagina is now to be expanded by 
a Sims speculum or by retractors, and the neck of the uterus seized and 
drawn downward and forward by a hook. The operator then makes a trans- 
verse incision through the vagina behind the cervix uteri, and through this 
incision the finger or a blunt hook is to be passed, and the foetus extracted. 
Should the head present, it can be grasped by a small pair of obstetric 
forceps and delivered. 
Placenta.-The important question connected with all operations for the 
removal of extra-uterine foetuses is the proper management of the placenta; 
and obstetricians are not in accord on this subject. 
Its detachment from a surface which has no muscular power of contrac- 
tion, and which therefore is without power to close the sinuses or vessels, 
necessarily exposes the woman to the risk of hemorrhage; and death has 
followed in several instances from this cause. 
On the other hand, the risk of septic poisoning must be considerable when 
a putrid mass like the placenta is allowed to remain. In a case upon which 
I operated, the organ was taken away, and no hemorrhage followed its ex- 
traction. Parry has published an analysis of 52 cases. Of this number the 
placenta was wholly or in part removed 24 times, with 12 deaths and 12 
recoveries, or a mortality of 50 per cent. In 28 cases where it was permitted 
to remain, there were 10 deaths,-a death-rate of 35.71 per cent. The com- 
parison consequently gives a percentage of 15.29 in favor of allowing the 
placenta to remain; and this is in accord with the opinion of a majority of 
the best authorities on the subject. Whether the operation is performed 
through the vagina or through the abdomen, the cord is to be brought out of 
the external wound, eight or ten days being required for the disengage- 
ment of the placenta. 
In a case under the care of Dr. Elwood Wilson, in which the foetus had 
reached maturity, I was able, without difficulty, to remove a dead child by 
opening Douglas's cul-de-sac through the vagina. Unfortunately, the sac in 
this case communicated with the peritoneum, in consequence of which the 
injection used to wash out the sac passed into the cavity of that membrane 
and destroyed the patient. 
The merits of this operation have not been fully determined. Parry has 
collected 15 cases, of which 9 mothers died and 6 recovered,-a mortality of 
60 per cent.; 2 out of the 15 children only were saved. I cannot, however, 
avoid believing that when the foetus distinctly presents itself in the vagina, 
this operation should be preferred to any other. 
Abdominal Section-Laparotomy, or Gastrotomy.-In removing the extra- 
uterine foetus by this method, the incision is to be made in the median line 
of the abdomen, between the umbilicus and the pubes, with the same method- 
ical division of the parietes as in ovariotomy, The sac is to be opened, the 
foetus extracted, and if the cyst-wall is not already adherent to the abdominal RUPTURE OF THE SAC. 
835 
walls it is to be stitched to the latter, a drainage-tube introduced, and the 
external wound not closed to its full extent, but allowed to close by granula- 
tion, during which the sac is to be washed out with antiseptic solutions, as 
that of permanganate of potash or very dilute Monsel's solution of iron,-one 
part of the iron to twenty parts of water. 
The mortality attending gastrotomy is influenced much by the previous 
existence or non-existence of adhesions between the cyst and the abdominal 
walls. In a collection of 62 gastrotomies,* 30 recovered and 32 died,-a death- 
rate of 51.61 per cent. The subject of adhesions is noticed in 24 cases. In 
17 such adhesions existed, and in 7 they were absent. Of those in which 
adhesions were present, 11 recovered and 6 died,-a death-rate of 35.29 per 
cent.; and of those in which they were absent, 3 recovered and 4 died,-a 
mortality of 57.14 per cent. 
The earliest operation of gastrotomy for the removal of the product of 
extra-uterine foetation, according to Parry, was made by Primerose, in the 
year 1594, the patient having, three years previously, expelled an extra- 
uterine foetus through the abdominal walls by the combined agency of ulcer- 
ation and artificial enlargement of the opening. In 1714 a second operation 
was done in France, by Culvo, and a third in this country, in New York, by 
Dr. Baird. The second and third operations of this kind done in this country 
were by Dr. Baynham, the first in 1791, on the wife of a Virginia planter, and 
the second in 1799, on a negro slave, both proving successful. Not until 1823 
was the operation again performed, when it was done by Dr. Wisbart; and 
in 1846 a sixth gastrotomy for extra-uterine foetation was executed by Dr. 
Stevens, of New York City. 
In Philadelphia, the extraction of the products of an extra-uterine preg- 
nancy has been done by W. F. Atlee, Goodell, and myself. 
Rupture of the Sac.-When an accident of this nature takes place, which 
is indicated by a feeling on the part of the woman that something internal 
has broken, immediately followed by severe pain, a pale countenance, nausea, 
a cold perspiration, and faintings, all of which are the ordinary signs of in- 
ternal hemorrhage, there remains no hope for the patient except in an 
immediate resort to gastrotomy, and, after extracting the foetus, tying or 
closing by the cautery any vessels that continue to bleed. 
Several interesting questions arise with regard to the propriety of opera- 
tive interference in cases of extra-uterine foetation. It appears that the mor- 
talityfollowing operations amounts to 51.61 per cent., while in the cases left 
to the natural processes of elimination the mortality is 52.65 per cent., leaving 
only one per cent, in favor of the operation. 
What is the proper time to operate ? Should it be done in case of rupture 
of the sac ? or, this danger escaped, at any period when the delivery of a 
viable child is possible, for example, between the seventh and ninth months? 
and, finally, what course is proper after the period of maturity is passed? 
In answer to the inquiry as to what course is proper in the event of rup- 
ture of the sac, it may be said that it has been shown that without surgical 
interference the accident is uniformly fatal, and consequently laparotomy 
holds out the only gleam of hope for the mother. As this accident generally 
happens before or about the fourth month, of course the preservation of the 
life of the foetus does not enter into the calculation. 
When the danger of rupture is passed and the child reaches that stage of 
maturity which admits of its being extracted alive, what is the duty of the 
surgeon ? Of 20 women operated on within the limits indicated, 14 died,- 
a mortality of 70 per cent., or a death-rate of 17.39 per cent, greater, so far 
as the mother is concerned, than when the case is left without interference. 
Again, what is the duty of the practitioner when the period of maturity 
is passed, or when the foetus has perished ? Under these circumstances it is 
deemed best by very competent authorities to withhold active interference 
* Parry on Extra-Uterine Pregnancy, p. 242. 836 
SURGICAL DISEASES OF WOMEN. 
and wait for nature to make some sign. The irritation which is likely to 
develop in the cyst may be instrumental in uniting the sac to the abdominal 
walls, in which event the success of an operation, should it become neces- 
sary, is enhanced to the extent of about 22 per cent. Or an effort may in the 
mean time be made by nature to expel the foetus by ulceration, in which 
process the chances of recovery are almost as great as by operation. It is 
also within the range of probability that through a retrograde metamor- 
phosis the cyst and its contents may be transformed into some harmless 
substance and become quiet. 
If none of these terminations occur, and the life of the mother is threatened 
as a result of local and constitutional irritation, there can be no objection to 
surgical interference, particularly after the woman has recovered from the 
perturbation incident to the puerperal state. 
Lastly, when fistulae have formed and portions of the foetus are being dis- 
charged, shall the surgeon quietly look on, or shall he aid the process by the 
resources of his art,-that is, by enlarging the openings and extracting pre- 
senting portions of the child ? Certainly he should adopt the latter course; 
though in making such enlargements he must be sparing in his incisions, 
for fear of transcending the limits of adhesion between the cyst and the part 
to which it is attached. 
The introduction of Listerism into abdominal surgery will no doubt in 
time render necessary some modification of the above formulae. 
Rupture of the Uterus. 
Rupture of the uterus is an accident of a very serious nature. It is pro- 
duced by the power of its own contractions, by the rude use of instruments, 
or in consequence of violence applied to the walls of the abdomen. 
If, during labor, after a pain of extraordinary severity there follow a sudden 
calm, a flattening of the abdomen, a progressive pallor of the face, a clammy 
perspiration, accompanied by a feeble pulse, cold extremities, and extreme ex- 
haustion, the accoucheur has good reason to suspect a laceration of the womb. 
And when with these symptoms the uterus is empty, or the child has only 
partially escaped from it, the diagnosis becomes certain. 
Treatment.-After the occurrence of such an accident there is no time for 
temporizing or delay. Unless the physician interferes for her rescue at once, 
the patient must soon perish from hemorrhage and shock. 
If the foetus has not entirely passed through the rent, the presenting part 
must be seized and the child brought away through the vagina, either by 
traction with the hands, or, in case the head remains in the organ, by instru- 
mental means. 
When the foetus has passed wholly into the abdomen of the mother, the 
only hope for the mother is in the Caesarean section. The operation has 
been twice successfully performed in Philadelphia, once by the late Dr. Wil- 
liam Byrd Page and once by the late Professor John Neill. Both mothers 
were saved, but not the children. 
In 40 cases of laceration of the uterus during labor, reported by Dr. Harris, 
21 of the mothers recovered, 2 children were extracted alive, and 38 dead. CHAPTER XXII. 
SURGICAL AFFECTIONS OF THE SPINAL OR DORSAL REGION 
-MALFORMATIONS OF THE HEAD FROM EFFUSION. 
Under this head will be considered the surgical diseases of the soft parts 
overlying the spine, diseases of the vertebrae, and diseases of the spinal 
marrow and its membranes. 
Diseases of the Soft Parts. 
Inflammatory peculiarities.-The integuments overlying the spinal region 
are remarkable for their density, compactness, and elasticity, in these re- 
spects resembling the scalp. Hence inflammatory attacks of the skin are 
prone to be of an erysipelatous or phlegmonous character. For the same 
anatomical reasons the back is often the seat of carbuncular attacks, espe- 
cially the cervical part of the spinal region, where the skin is thickest. 
Wounds.-Wounds attended with even a trifling loss of substance rarely 
unite by quick union. Traction is not well tolerated, and if attempted 
develops inflammation, and the sutures quickly cut through, permitting the 
parts to gape, and leaving a chasm to be filled by granulation tissue. 
The arteries which are distributed in the soft parts of the back are not 
large, and consequently wounds of this region of the body are rarely fol- 
lowed by any considerable hemorrhage. The veins are remarkable for their 
size and the tortuous disposition of their trunks. 
Blood tumors.-Blood tumors, the result of contusions, are very common, 
and often attain a large size. In most instances they disappear sponta- 
neously by absorption, demanding only the local application of a compress 
wet with alcohol or a solution of muriate of ammonia and retained by firm 
pressure, made either by a broad bandage or by adhesive plaster. 
Eruptions.-Eruptions over the dorsal region, especially if syphilitic, usually 
yield more reluctantly to treatment than those located on other parts of the 
body. 
Furuncles.-The rich supply of cutaneous glands over the spinal integu- 
ment favors the production of furunculous inflammation, though it will be 
found that in such cases there is never a large amount of pus as compared 
with the necrosed cellular tissue. The treatment of furuncle will not differ 
from that proper to boils elsewhere. 
Abscesses.-The abscesses which appear in this region are oftener deep than 
superficial, and are always suggestive of disease of the bony structure of the 
vertebrae. Abscesses having such an origin reveal their true source by their 
course, shape, and location. The anatomical student will have observed that 
the erector spinae muscles which lie on either side of the spinal column, filling 
up the vertebral grooves, are bound in position at the loins by a powerful 
aponeurosis, which also gives attachment to the vertebral extremities of 
the broad abdominal muscles. This aponeurosis arises by three leaves, one 
from the spinous processes of the lumbar vertebrae, one from the transverse 
processes, and the third from the bodies of the vertebrae at the root of the 
transverse processes. Between the spinous and transverse layers lie the 
erector spinae muscles, and between the transverse and anterior layers the 
quadratus lumborum muscles. 
Over the dorsal division of the vertebrae this aponeurosis is much less 
powerful, and is lost with the connective tissue on the sides of the trunk, 
837 838 
SURGICAL DISEASES OF THE SPINAL REGION. 
being covered by the broad muscles of the back, which are inserted on the 
scapula and the humerus. The surgical importance of this disposition of 
structure is as follows. First, an abscess in the upper portion of the spinal 
region proceeding from dead bone may be compelled to follow the course of 
the erector spina) muscles, and open very much lower down than the source 
from which it originates. Thus, a fistulous orifice which appears in the 
lumbar region may be traced upward to the neck. Second, a collection of 
pus, owing to the agency of gravity, and to the external and internal limi- 
tations of this lumbar fascia, will assume an oblong form, its major axis being 
parallel with the spinal column. Third, an abscess which is connected with 
disease of the lumbar vertebra) rarely opens on the surface of the loins, the 
strength of the aponeurosis in this region preventing such a course, and 
hence the accumulation, following the middle leaf of the fascia, advances 
forward between the abdominal muscles, and appears in one or other of the 
iliac regions at some point above Poupart's ligament. 
All incisions which are made over the posterior part of the body for the 
removal of morbid growths should have a direction parallel with the course 
of the muscles; that is, parallel with the course of the spine when the struc- 
tures to be divided are near that column, and oblique with it when the knife 
is applied over the latissimus dorsi or trapezius muscle. 
The loose attachment of these broad muscles of the back makes it necessary 
to compress firmly a wound which has gone deeper than the muscles; other- 
wise, in the movements of inspiration, hemorrhage may be brought on, and 
a large collection of blood may find its way over the walls of the chest 
beneath the muscles. 
Tumors.-Adipose tumors are the most common of all morbid growths in 
this region of the body, and attain in some instances a very great bulk. An 
aged German woman entered my office 
on one occasion, having what I sup- 
posed to be a peddler's pack strapped 
across her shoulders. Upon removing 
the clothing, she exposed an enormous 
lipoma suspended in a bag, and on 
withdrawing the support of the latter, 
the tumor, attached to the lower part 
of the neck, hung down almost to the 
loins. (Fig. 1519.) Its great weight 
had elongated the attachment of the 
mass into a pedicle, giving it a pyri- 
form figure. 
The friction to which the integu- 
ment at the line of the cervical and 
cervico-dorsal regions-the most com- 
mon seats of these tumors-is ex- 
posed from the weight of the clothing 
has much to do with the development 
of adipose growths. I have noticed 
them to be frequent upon the neck 
and shoulders of farmers at the points 
where the weight of the grain-bag 
used in sowing had been habitually 
supported. 
Adipose tumors in the region under 
consideration are rarely found free or 
very movable, noi' are they ever en- 
capsulated in a loose layer of connective tissue, as occurs in other portions of 
the body. The fat, also, which composes the neoplasm is in coarse granules 
instead of being in lobular masses. These peculiarities render their removal 
Fig. 1519. 
Lipoma of the back. DISEASE'S OF THE SOFT PARTS. 
839 
always somewhat difficult, as a tedious dissection has to be substituted for 
enucleation with the fingers. 
Excision is the remedy for fatty tumors of the neck. 
Sarcoma of the back is not common. The disease occasionally develops 
in the cicatrix or bed from which an adipose growth has been excised. I 
removed on three different occasions a round-celled sarcoma from the back 
of a prominent physician of Lancaster City, which started originally in the 
place from which a fatty tumor had been previously excised. At each suc- 
cessive reappearance of the tumor the growth occurred lower down, so that 
the disease, which was at first situated on a line with the lower angle of the 
scapula, finally occupied the lumbar region, the parts above remaining sound. 
It would seem that the elements of the neoplasm were influenced by gravity. 
The hemorrhage at each operation was considerable. The patient, after the 
lapse of two years, succumbed to the disease. 
Fibroma.-Fibrous tumors are also among the morbid affections of the 
back. Their distinguishing physical characteristics are firmness of struc- 
ture, fixedness of position, depth of situation, and a dull, heavy pain; their 
growth is slow. They originate in the connective tissue which underlies the 
muscles of the back. Only when the tumor exhibits a steady tendency to 
grow is it necessary to interfere, in which case excision will be proper. Small 
pendulous tumors, consisting of skin and connective tissue attached by narrow 
pedicles, are often found upon the back, and, as they are liable to become 
irritated by the clothing, may be clipped off. 
Angeiomata, or ncevi, are frequently witnessed on the back. The venous 
element, I think, generally preponderates, and they almost always extend 
down to the aponeurosis or muscles over which they are placed. Their growth 
is often very rapid. I removed, successfully, in a child, a patient of Dr. 
Wickoff's, of Princeton, a nsevus from this region, which in a single year 
had become five inches long, two inches broad, and projected from the surface 
in a great, blue, spongy roll half an inch in height. 
Naevi can easily be distinguished by the red color or the blue tint discover- 
able through the skin ; by their soft, spongy feel; by the facility with which 
they can be emptied of their blood by compression ; and by the readiness with 
which they become distended under the excitement of crying. 
The treatment consists in removing the diseased mass either by excision 
or by ligature. (See Angeioma, vol. i. page 506.) 
Sebaceous tumors.-Though the sebaceous glands are very abundantly dis- 
tributed over the back, the sebaceous tumor or cyst cannot be regarded as 
common in this region. It is known by its rotundity, slight elasticity, and 
tardy growth, and by a minute dark point visible in the centre and marking 
the position of the remains of the excretory duct. Subjected to the friction 
of clothing, sebaceous tumors sometimes become tender, inflamed, and sup- 
purating ; in such event they should be laid open, the contents turned out, 
and the sac removed. 
Epithelioma.-Some of the most extensive examples of epithelioma are met 
with in the back. I saw, with Dr. Levis, of this city, an ulcer of this char- 
acter along the side of the spine which was not less than seven inches in its 
smallest diameter. The edges of the sore were irregular and everted, its 
sides shelving, and the discharge ichorous, exceedingly copious, and offensive. 
Early removal with zinc paste, caustic potash, or the knife, and filling the 
chasm by transplanting a flap of sound integument, constitute the proper 
treatment. 
Encephaloid and melanotic cancers of the back present all the characteristics 
of these formidable affections elsewhere, namely, elasticity, irregularity of 
surface, and rapid growth. The most tbet can be claimed for an operation 
is palliation. Too often the knife imparts an additional momentum to the 
disease, and hastens an event which a more conservative course would have 
delayed. 
The melanotic variety can be distinguished by its dark color, superficial 840 
SURGICAL DISEASES OF THE SPINAL REGION. 
position, resistance to pressure, and knotty surface. Males more commonly 
suffer from melanotic disease. 
Several tumors of the kind may exist at the same time, none of which 
attain any great size, the disease being remarkable for its tendency to multi- 
plication rather than for the bulkiness of the neoplasms. 
Congenital tumors at the lower extremity of the spine arc not uncommon. They 
are situated usually over the sacrum or the coccyx, and, occupying as they 
do the median line, their diagnosis is not a little embarrassing. These growths 
are cystic, fatty, sebaceous, and dermoid. 
Cystic tumors.-These, coming out as they do sometimes between the 
arches of the vertebrae, I am disposed to believe are in many instances hy- 
drorachitic in their nature, the neck of the sac having undergone a sponta- 
neous closure, but the lining membrane of the tumor continuing to secrete 
and the cyst to grow. So far as the composition of their contents is con- 
cerned, it does not differ from the fluid found in hydrorachis. As it is im- 
possible always to distinguish these cysts from those in spina bifida, it will 
be necessary, when the removal is decided upon, to make a careful dissection 
•of the elliptical flaps which are taken from the base of the tumor, until the 
true relations of the neck of the sac are ascertained, when, if traced to the 
theca of the cord, and not through its membrane, removal will be proper. 
If, on the other hand, a communication exists between the tumor and the 
arachnoid or subarachnoid space, it will be better to replace the flaps, and, 
after recovery from the operation, to proceed as in a case of hydrorachis. 
Fatty tumors over the sacral region are tabulated, with hard, deep con- 
strictions between the lobules. They are sometimes globular, but more 
commonly conical and twisted. They may start within the spinal canal, as 
happened in the cases recorded by Mr. Athol Johnson and by Mr. Pollock.* 
Should they cease to enlarge, they may be safely left alone, as it is not im- 
probable that after a certain period they will diminish and shrivel up, leaving 
only a tag of corrugated integument. If, however, the growth continues to 
increase, it should be excised. 
Dermoid tumors.-The sacral region is a favorite locality for the develop- 
ment of cysts which contain teeth, hair, etc. The sebaceous cyst is probably 
of this nature. These tumors may be attached to the sacrum, or their attach- 
ment may exist within the pelvis, the tumor coming out between the sacrum 
and the coccyx. 
. Foetal tumors.-Numerous examples of tumors containing foetal remains, 
as cartilage, bone, etc., are recorded by medical authors, as are also cases in 
which a part of another child, as a leg, has grown from the sacrum, or in 
which a tumor, similarly attached, has contained a portion of the intestine. 
The treatment, in such monstrous developments, is removal by the knife 
or by the ligature, when there is reason to believe that the tumor does not 
communicate with the spinal marrow or with some important organ. 
Bursal tumors.-Immediately over the vertebra prominens is placed a large 
bursal sac, which, under the weight of a heavy overcoat or othei* clothing, is 
liable to become inflamed and cause considerable suffering. 
The nature of the swelling will be disclosed by its situation at the junction 
of the cervical and dorsal regions of the spine, and by its tenderness to press- 
ure. All pressure must be taken off this part of the neck. To effect this 
I have frequently employed a pad stuffed with cotton, having an opening in 
the centre to receive the enlargement, and held in position by being stitched 
to the under-clothing. At night the application of a lotion of lead-water and 
laudanum will give great relief. I have never been compelled to resort to 
any more radical measures. 
Sprains of the Spine are accidents to which quarrymen, carpenters, and 
railroad operatives are peculiarly liable. When of a severe character the 
spinal marrow may participate in the injury. If the force i« applied directly, 
* Transactions of the London Pathological Society, vol. viii. SPLAINS OF THE SPINE. 
841 
there follows, of necessity, more or less contusion of all the soft parts, in- 
cluding the muscles; but even when the force is indirect, the latter do not 
escape. They are injured either in the extraordinary efforts which are made 
by the subject of the accident to save himself from the impending danger, or, 
taken by surprise, their fibres may be torn, or their tendons be displaced. 
The swelling, which quickly succeeds violence, is caused by the laceration of 
vessels, chiefly veins; and in severe cases the disordered sensibility and loss 
of motion imply that either the spinal nerves before or after they emerge 
from the intervertebral foramina, or possibly the spinal cord, or both, have 
sustained some harm, most likely from the pressure of blood. Hsematuria 
sometimes follows severe injuries of the lumbar spine, but I can recall no 
case where renal hemorrhage was present unless the force producing the 
accident was direct. Indeed, it is highly improbable that mere flexion or 
extension independent of direct violence could affect the kidneys to a degree 
sufficient to produce such a result. 
Hscmaturia may follow a sprain of the loins which is brought about by 
voluntary muscular efforts, as in raising some body of great weight; but 
here there is an element introduced which is absent in ordinary accidental 
sprains, namely, the forcible pressure of the viscera by the abdominal muscles 
against the emulgent veins so as to cause congestion and rupture of some of 
the renal vessels. 
Diagnosis.-A spinal sprain followed by great helplessness and some degree 
of paralysis may simulate fracture of the vertebra?. In the latter, however, 
the disability is complete. The patient lies on his back, unable to turn upon 
the side, or even to remain there when so placed, as he can in sprain. 
Besides, in sprain the tenderness is more diffused than in fracture, nor is 
there ever any irregularity in the line of the spinous processes. Paralysis is 
a uniform, accompaniment of fracture, but not of sprain, and when present 
in the latter it is much less pronounced than in fracture, and soon dis- 
appears. 
Treatment.-Taking any of the cases which have been cited as a type of 
spinal strain, the treatment proper to be adopted will be, in case the injury 
has been received in the cervical region, to place the patient on the back, 
with the head and neck resting on a soft pillow and supported on each side 
by a short bag of sand. Blood should be drawn from the part by cups or by 
leeches, and over the entire back of the neck, followed by the application of 
lead-water and laudanum. In a few days, or after the first effects of the in- 
jury have passed off, great comfort will be experienced from imbedding the 
posterior part of the neck in a flaxseed-meal poultice, which can be kept 
moist and warm by placing over it a piece of oiled silk or rubber-cloth. Rest 
is to be procured by the bromide of potassium, or by some preparation of 
opium. The bowels should be moved once every two or three days, and the 
diet for the first three or four days must be restricted and simple. 
When the sprain is in the lumbar or sacro-lumbar region, the dorsal position 
is not the most comfortable; the patient will usually seek that on the side. 
After the acute symptoms have subsided, there will remain a considerable 
degree of soreness and stiffness, aggravated always by the patient attempting 
either to sit or to stand, and which is seldom got rid of under ten or twelve 
weeks. During this period the best applications are stimulating lotions, as 
soap liniment mixed with oil of amber, or tincture of aconite and chloroform, 
aided by judicious "massage." 
It is best, particularly when the sprain is in the loins, not to insist on the 
erect position before the disappearance of much of the soreness. 
When the patient begins to leave bis bed, great assistance will be derived 
from the use of a plaster bandage applied about the hips and loins. An arti- 
ficial support of this kind will enable the person to sit or to walk without 
exacting too much from the enfeebled muscles of the spine. This bandage 
must not be worn too long, otherwise the muscles will waste. Accordingly, 
after three or four weeks it should be laid aside. 842 
SURGICAL DISEASES OF THE SPINAL REGION. 
Spinal Myalgia. 
In this place may be appropriately considered a very common affection 
of both the lumbar and the cervical region, characterized by a sudden and 
severe pain in the muscles of the loins or of the neck, and which occurs 
while stooping down, or while twisting the body, or sometimes in the act 
of drawing on a boot. It is described under different names, as lumbago, 
" crick," myalgia, etc. It rarely lasts more than three or four days, and 
occasionally disappears as suddenly as it came. In many cases the attack 
is undoubtedly rheumatic, but in others it is due to the displacement of a 
muscular fasciculus, the sheath of which has given way, or to a similar dis- 
location of one of the numerous small tendons belonging to the muscles of 
the spine. 
The differential diagnosis between the spinal myalgia resulting from rheu- 
matic causes and that arising from muscular displacement may be approxi- 
mately established by the following considerations: 
In the former, motion in almost any direction is attended with suffering, 
and the soreness and tenderness are diffused; in muscular displacement the 
distress or pain will be local, and confined to some single movement. Besides, 
a careful inspection of the surface will sometimes reveal a small dimple or 
depression, or possibly a little bulging, either of which marks the seat of the 
displacement. 
Treatment.-Rheumatic spinal myalgia requires cupping over the affected 
region, followed by stimulating frictions and full doses of quinine. Rest, 
which naturally falls in with the feelings of the patient, is not always de- 
sirable. The disease will often disappear more quickly if moderate exercise 
is taken. 
Should the pain linger beyond three or four days, showing no disposition 
to leave, the cure will be hastened by the internal administration of iodide 
of potassium with wine of colchicum. Beating the muscles gently with a 
gum ball attached to an elastic rod, until the surface becomes red, will often 
prove a valuable adjunct to the treatment. 
When there is reason to believe that the pain is due to muscular or ten- 
dinous dislocation, the remedy is reduction. To accomplish this, let the 
patient first assume the posture which causes the severest pain, and then 
let him change the position to one exactly opposite, when the surgeon thrusts 
the fingers into the seat of pain, pressing the parts away from the side 
towards which the body of the patient is inclined, and directing him at the 
same time to resume a natural posture. If there has been no error in the 
diagnosis, the manipulation will most likely be followed by an instantaneous 
relief from pain. 
Injuries of the Spinal Cord. 
The relation which the spinal cord sustains to the spinal canal, resembling, 
in many respects, that which subsists between the brain and the cranium, 
naturally suggests a similar classification of its injuries and diseases. Thus, 
we have the so-called concussion and compression of the medulla spinalis, 
equivalents of concussion and compression of the brain. 
Concussion.-When it is considered that the medulla spinalis is closely em- 
braced by its pia mater, that it does not fill the spinal canal, that its con- 
nections with the latter are only at points where the nerves pass through the 
intervertebral foramina, that it is surrounded by a stratum of fluid, and 
that in the structure of the vertebrse and their connections everything con- 
spires to neutralize vibrations, it is impossible to believe that concussion of 
the cord can be a very frequent accident. Indeed, I am at a loss to know, 
either from clinical experience or from the revelations of the dead-house, 
what phenomena disclose uncomplicated concussion of the spinal cord. Cases INJURIES OF THE SPINAL CORD. 
843 
of death have been reported from spinal concussion, as they have been from 
cerebral concussion, in which it is said that no lesions whatever could be dis- 
covered. But too often the examinations did not extend beyond the spinal 
canal, and are, therefore, not entitled to be accepted as final or conclusive 
in establishing the truth of the statements. The effects of violent injuries 
of the spine, both direct and indirect, arc not necessarily limited to the cord, 
but extend to the head and to the viscera, abdominal and thoracic; and in 
these instances of death without discoverable lesions it is probable that, unless 
life had been extinguished by shock, some of these cavities, had they been 
searched, would have surrendered the secret. 
The symptoms which are said to indicate concussion of the spinal cord- 
and by the term is meant a jar or shock which affects primarily the substance 
of the medulla spinalis within its membranes, independent of any lesion of 
the spinal column-may follow force applied either directly or indirectly. An 
individual falls from a height upon the buttocks; the violence is transmitted 
to the spine; it is followed by numbness, tingling, loss of power in the lowei* 
extremities, pallor of the face, and sickness of stomach, with probably vomit- 
ing. The symptoms are represented as the expression of a concussed spinal 
cord ; but every one may be present without the latter having realized a single 
vibration from the blow. The sacral nerves have probably received the brunt 
of the injury, and have given rise to the disturbances of sensation and motion ; 
and the shock sustained by the ganglionic masses of neurine within the ab- 
domen, which lie immediately in contact with the spine, would be quite 
sufficient to account for the gastric disturbance. 
Again, a blow applied to the cervical region of the spine may be followed 
by spasmodic contraction of certain muscles of the neck, or by temporary 
paralysis of an arm, by hiccough, or by a cord-like constriction of the body, 
yet all these phenomena are quite intelligible without assuming the existence 
of concussion of the cord, as the nerves concerned in producing these dif- 
ferent symptoms are all within the reach of contusion from the vulnerating 
body; and the symptoms are usually of temporary duration, indicating a 
peripheral rather than a central causation. 
A concentrated force delivered upon the lumbar spine is also said, in con- 
sequence of concussion of the cord, to induce paralysis, motor, sensory, or 
both, of the lower extremities, with a similar loss of power in the bladder 
and the rectum. But what proof have we that such effects are not the re- 
sults of compression of the cord from rupture of vessels within the spinal 
canal rather than of concussion? Until there is evidence more conclusive 
than any at present possessed, I must remain skeptical in regard to the ex- 
istence of spinal concussion as a sufficient cause for many of these phe- 
nomena. 
Mr. Erichsen has described a variety of spinal concussion arising from in- 
direct violence, which he believes to be peculiar to the shock incident to 
railroad collisions, independent of any detectable wound, bruise, or other ex- 
ternal injury, and characterized by secondary phenomena, both physical and 
mental, which are referable to an insidious chronic inflammation of the cord 
and its membranes. 
After an accident of the above character, a person who, by the sudden 
arrest of a car in rapid motion, is thrown violently forward, then rebounds in 
the opposite direction, or, it may be, falls with a severe twist, soon recovers 
from the confusion and shock attending the accident, with no abnormal feel- 
ings other than a little soreness or stiffness from having been shaken up, and 
perhaps a little tremor and faintness from the fright and excitement of the 
moment. Nay, more, he may be able to participate in the efforts made to 
rescue others from the wreck and give such other aid and relief as the unfor- 
tunate sufferers may require. Some time following, it may be almost imme- 
diately, or after several months, he becomes conscious that something has 
happened. A change, visible even to his friends and acquaintances, is noticed, 
though so undefined that it is difficult to say exactly in what it consists. His 844 
SURGICAL DISEASES OF THE SPINAL REGION. 
accustomed energy and interest in business begin to lessen; he finds himself 
unequal to the ordinary exactions of his calling; the memory fails in many 
particulars; there is more or less confusion of thought, an incapacity for 
mental concentration, an inability to sleep, or his slumbers broken by horrid 
dreams. Noted hitherto, perhaps, for calmness and amiability, he becomes 
impatient, fretful, and capricious. The organs of special sense are disturbed. 
The vision is defective, in consequence of which objects are seen double or 
confused ; flashes of light and floating specks frequently annoy him, and, 
in some cases, even strabismus is present. The hearing may be obtuse or 
over-acute, and noises strike painfully upon the ears. The sense of touch is 
modified, the patient, as in ataxic disease, being unable to seize small objects 
like pins, or to button his shirt or vest. The speech is sometimes altered, 
sentences being spoken with hesitation, or perhaps with stammering. In 
addition to these symptoms there is a peculiarity in the gait and in the atti- 
tude of the patient, indicated by the straddling, shuffling, and unsteady use of 
his limbs, and by the stiff, mechanical manner which is assumed in standing. 
In order to walk safely, he finds it necessary to fix his eyes steadily on some 
object in advance. Motion and sensation in the limbs differ in different 
cases. Sometimes both motor and sensory paralysis are present, affecting 
alike the upper and the lower extremities; at other times one leg and one 
arm, it may be on opposite sides of the body, are involved; in addition to 
which, various eccentric sensations are experienced, as pricking, tingling, burn- 
ing, crawling, etc. The nutrition, moreover, suffers; the muscles become soft 
and. waste; a slow and general emaciation may be observed; the strength 
continues to diminish, the paralysis becomes more pronounced, and the indi- 
vidual dies after an illness varying from a few months to several years. 
Such is a brief resume of the phenomena which are said to characterize the 
spinal concussion resulting from railroad collisions. 
Dr. Lockhart Clarke,* in one instance, examined the spinal cord and brain 
of a man who died between three and four years after receiving a severe 
concussion in a railroad accident without any external marks of injury, and 
whose symptoms answered, in the main, to those which have been detailed. 
There were in this case the usual signs of both spinal meningitis and myeli- 
tis, with a remarkable diminution in the antero-posterior diameter of the 
cord, especially in its enlarged cervical portion, and also a singular limitation 
of disease to the posterior white columns, indicated only by the presence of 
numerous compound granular corpuscles and scattering granules, many of 
the nerve-fibres having been replaced by a wavy fibrous tissue. There was 
also a general opacity of the cranial arachnoid, with a serous effusion beneath 
that membrane, and the gray matter on the under surface of the anterior 
lobes of the brain was found somewhat softened. 
It does not appear, however, that the initial change of structure in the ex- 
tensive and varied assemblage of morbid phenomena which characterized the 
case was primarily located in the cord; nor has it been proven that similar 
structural alterations in the cord and brain may not as often follow spinal 
injuries from other than railroad collisions. In other words, it is not clear 
that there is anything peculiarly distinctive or original in the concussions 
received by persons who encounter injuries from the collision of railroad 
trains moving at a high rate of speed. 
Wounds of the Spinal Cord are almost invariably fatal, the suddenness of 
the event being determined by the region involved, increasing as we ascend 
the cord, in consequence of the number of important parts paralyzed, until 
the cervical region above the origin of the phrenic nerves is reached, when 
death follows quickly. 
The cord may suffer in different ways from a vulnerating cause. The 
lesion may consist in a punctured, incised, or gunshot wound, and often of a 
fracture of the spine, in which the substance of the cord is compressed by 
* Transactions of the London Pathological Society, vol. xvii. p. 20. INJURIES OF THE SPINAL CORD. 
845 
hemorrhage or by a fragment or fragments of bone being driven into its 
substance and bruising, lacerating, or even entirely severing the cylinder of 
the medulla. 
A boy was brought into the University Hospital who survived for twelve 
hours, notwithstanding a ball had entered between the bodies of two cervical 
vertebrae and passed through the spinal canal, 
cutting the cord, and emerging between the spi- 
nous processes. Fig. 1520 is a cut taken from 
this preparation. 
The treatment will not materially differ from 
that proper to a case of fracture of the spine. 
The paralyzed soft parts should be protected as 
much as possible from the effects of pressure, 
and the bladder should be catheterized. In gun- 
shot wounds attended with comminution of the 
vertebrae, it will be proper to pick away any 
loose fragments which may press on the cord; 
but attempts to relieve compression by the use 
of the trephine are as useless after gunshot wounds as after fractures. In- 
flammatory symptoms affecting either the cord or its meninges as an effect 
of wounds should be met by the local application of leeches, followed by ice 
and by alterative doses of mercury. 
Fig. 1520. 
Perforation of cervical vertebras and 
of the cord. 
Compression of the Spinal Cord.-Compression of the spinal cord is pro- 
duced by traumatic and by inflammatory causes. The compressing material 
may be bone, blood, serum, lymph, or pus. 
Compression from bone has been considered while treating of fractures 
and dislocations of the vertebrae, and need not be again referred to in this 
place. 
Blood-pressure.-When the compressing agent is blood, there are three 
sources from which the hemorrhage may be derived: first, from the lacera- 
tion of veins in the spinal canal, between the latter and the theca of the cord; 
second, from the vessels between the cord and its membranes; and, third, from 
the vessels contained in the substance of the medulla. 
The first, namely, hemorrhage from the rachitic veins, I believe to be more 
common than is generally supposed. These vessels are thin-walled, large, 
and receive very little support from any surrounding tissue, and hence are 
liable to be ruptured by falls and blows, direct or 
indirect, upon the spine. The blood accumulates in 
the canal, gravitating towards its lower part, and 
encroaches upon the membranes and the medulla 
spinalis, as well as upon the vertebral part of the 
spinal nerves, exerting (Fig. 1521) sufficient com- 
pression in severe cases to suspend the functions of 
the cord, just as a similar clot within the cranium 
produces compression of the brain. 
Hemorrhage derived from the vessels within the 
theca of the cord is rarely seen independent of frac- 
ture of the vertebras; and the same is true with re- 
gard to *that occurring within the substance of the 
medulla, unless, as stated by Charcot and Hayem, 
there has been a preceding myelitis, when it is likely 
to follow, laceration of the membranes being a com- 
mon attendant in both. 
When the blood which collects in the canal is in 
sufficient quantity to cause paralysis, it may be disposed of by the vessels, 
whether coagulated or not, and with the removal of the compressing mate- 
rial will likewise disappear the motor, sensory, or moto-sensory paralysis 
which may have been present. 
Fig. 1521. 
Clot of blood in the spinal canal 
from rupture of the spinal veins. 846 
SURGICAL DISEASES OE THE SPINAL REGION. 
It is not possible to distinguish with certainty from what vessels the blood 
in a case of spinal hemorrhage comes. The following considerations furnish 
reasonable grounds for a diagnosis : 
First. The space which exists between the cord and the walls of the spinal 
canal is so considerable that it will require some time (a few hours) after an 
injury before the accumulation will be large enough to make sufficient press- 
ure on the medulla spinalis to develop paralysis. The latter is likely, from 
this very circumstance, to be gradual in its appearance. When, on the other 
hand, the blood issues from the vessels of the membranes, or from those in 
the substance of the cord, the compression will be sudden, immediate, and 
direct, and the paralysis instantaneous. 
Second. When the hemorrhage comes from the veins of the canal, the sub- 
stance of the cord is less exposed to injury and the symptoms of compres- 
sion are more likely to disappear than when the blood is derived from either 
the vessels of the meninges or those of the spinal marrow. As in the former 
case, the extravasation is not in contact with the medulla spinalis, and the 
coagulum is more easily disposed of through the agencies of the veins and 
lymphatics. 
Compression from lymph, serum, or pus has, necessarily, an inflammatory 
history,-a precedent meningitis or myelitis. 
Meningitis may arise from contusion of the spinal nerves or of their sheaths 
as the former leave the intervertebral foramina; or the inflammation may be 
propagated to the meninges from carious vertebrae, as in Pott's disease of 
the spine, independent of any traumatic excitant. If the meningitis ter- 
minates in the transudation of serum, lymph, or pus, compression of the cord 
follows, and with it a certain degree of paralysis. The time at which the 
latter appears will depend on the chronicity of the meningeal inflammation, 
-seldom, perhaps, earlier than a week or later than six weeks. 
It is possible to have symptoms of compression of the cord from pus with- 
out any antecedent disease of the meninges, as when the contents of an 
abscess in a diseased vertebra force their way into the spinal canal. In in- 
stances of this kind, however, there will have been a previous history of 
spinal osteitis, and the signs of compression, or the paralysis, will probably 
occur suddenly. 
Myelitis.-A meningitis may become a myelitis, but the secondary con- 
dition is not likely to succeed the first very rapidly, requiring, perhaps, six 
or eight weeks. When, however, the inflammation at length invades the 
cord, the latter rarely escapes serious alterations in its structure. The morbid 
changes may be local or diffused, sometimes involving the white substance 
of the medulla spinalis, producing softening, and sometimes affecting the axis 
of the gray substance; while in other instances of chronic myelitis there is at 
the commencement of the disease a remarkable increase in the cell-forms of 
the neuroglia, and with this increase a corresponding wasting of the nerve- 
fibres. The resulting thickening or sclerosis affects usually the posterior 
column of the cord, and constitutes the degenerative characteristic of loco- 
motor ataxia. 
Those degenerations of the cord which succeed to traumatic violence are 
in a very large proportion of cases the result of disease propagated from 
without inward, and do not originate in the medulla spinalis. It is thus, I 
believe, that after violent wrenches, contusions, twisting, or straining of the 
spinal column, its ligaments and articulations, a slow, insidious inflamma- 
tion, beginning in the sheaths of the nerves in the periosteum or in the 
connective tissue which lies in the irregularities of the vertebrae, creeps 
along these lines of conduction until the membranes of the cord are reached, 
and, finally, the cord itself, after which follow those tardy central degenera- 
tions of structure in which progressive paralysis plays so conspicuous a part, 
and which entail an invalidism worse than death itself. 
Laceration of the meninges and of the cord is an accident almost peculiar 
to fractures and dislocations of the vertebrae, in which a displaced portion of INJURIES OF THE SPINAL CORD. 
847 
the broken or dislocated bone is driven into the spinal canal. The pia mater 
invests the cord so closely that it may be torn without the other membranes 
participating in the lesion. This accident is likely to follow extreme flexion 
of the spine, and when the membrane gives way the nerve-substance of the 
cord presses through the rent. 
It will appear from the preceding remarks that paralysis as a result of 
traumatic violence has a broad pathological significance, and the question 
naturally arises, Is it possible, in every instance, to determine the nature of 
the producing cause? 
In answering this question, it must be admitted that there is always some 
uncertainty in the diagnosis of spinal injuries, more, indeed, in regard to 
causation than in regard to lesion. 
In endeavoring to establish the relation between spinal lesions and their 
usual causes, it will be necessary to ascertain the time at which the symptoms 
appear after the receipt of an injury, and their nature and severity. With 
regard to the question of time, we may formulate our knowledge as follows: 
1. When the symptoms occur instantaneously after the reception of some 
violence communicated to the spine, the lesion is probably a central one, 
affecting the substance of the cord, and the cause is pressure from bone. 
2. When the symptoms develop only after the lapse of several minutes or 
hours, the lesion is intraspinal, and the cause is pressure produced by rupture 
of blood-vessels situated either between the walls of the spinal canal and the 
membranes or within the latter and the cord, the delay in the paralysis being 
due to the fact that some time is required for the blood to accumulate in 
sufficient quantity to interfere with the functions of the cord. As to the 
particular vessels implicated in the injury, it may be affirmed that the more 
rapidly the symptoms of pressure appear the stronger will be the evidence 
that the hemorrhage comes from those within the membranes, as, when from 
this source, the extravasation has not the same room for diffusion as when 
the blood is derived from the veins of the spinal canal, and consequently the 
pressure is more concentrated. 3. When symptoms are delayed until after 
the lapse of six or seven days, or even perhaps one or two months, it is rea- 
sonable to refer them to inflammatory causes, pressure being due to serum, 
lymph, or pus,-the product of a meningitis or a myelitis, or of both. 
Symptoms may be postponed for even eight or ten months after an injury; 
and when this is the case it is evidence of there having been an intermediate 
inflammation of an extremely chronic or negative character, which has 
caused serious, most likely incurable, degeneration of the cord. 
The differentiation of the phenomena which are meningeal from those 
which are central or located in the cord is often difficult, many symptoms 
being common to both peripheral and central disease. 
Pain in the spine, though more common in meningitis than in diseases of 
the cord, has not much diagnostic importance in the present connection, inas- 
much as it has a wide range of causation, being present in diseases of the ver- 
tebrae, in rheumatism and neuralgia of the back, and in different disturbances 
■of the digestive organs. More importance is to be attached to those pains 
which are uniformly experienced in certain parts supplied by the sensory 
nerves. These are believed to indicate a central rather than a peripheral 
irritation; and, although the seat of irritation may be located either in the 
cord or in the membranes at some point between where the nerves emerge 
from the medulla spinalis and where they leave the intervertebral foramina, 
yet as a means of separating those symptoms which in their origin are extra- 
spinal from those which are intraspinal they possess great value. 
There are, nevertheless, paius of a certain quality which are quite pathog- 
nomonic,-those, for example, which are darting, shooting, brief in their 
duration, like an electric flash, or those which convey the impression of con- 
striction. These pains are often associated with certain modifications of sen- 
sation, as pricking, numbness, and a feeling as though some soft fabric, like 848 
SURGICAL DISEASES OF THE SPINAL REGION. 
velvet, was being passed over the surface. These symptoms all point to 
serious degeneration of the cord. Muscular spasms occurring early after an 
injury of the spine indicate acute meningitis, as in this inflammation the 
reflex centres are preternaturally excited. When the spasms appear late in 
the progress of the case and are gradually developed, they are most probably 
dependent on disease of the lateral columns of the cord. 
Again, changes in the nutrition of the muscles afford valuable information 
in regard to the seat of the lesion. The influence which administers to the 
nutrition of the muscles finds its way from the cord to those structures along 
the motor fibres or the anterior roots of the spinal nerves; and whatever 
interrupts the passage of the nerve-fluid along these paths of conduction is 
followed by the atrophy of the muscles or groups of muscles to which these 
nerves are distributed. 
It is here that electricity comes to our aid. In the healthy condition of 
the motor nerves the application of either the faradic or the galvanic current 
excites contraction in the muscles supplied by their branches, continuous 
when the stimulus is faradic and intermittent when voltaic. If, therefore, 
on applying those tests, no movements can be excited in the paralyzed mus- 
cles and there is no evidence of the nerve-cord being compressed or severed, 
the legitimate deduction is that the lesion is central. It is possible, in some 
instances, to find the susceptibility to faradic stimulation lost, while the 
voltaic irritability is increased. This occurs in degeneration of the nerve- 
fibres. 
The loss of certain reflexes, as that of the tendo patellae, the ankle, and 
the cremaster, is regarded as strong evidence of central disease. These reflex 
movements are made as follows: 
In the case of the patella reflex, if the leg is allowed to hang without re- 
straint at right angles with the thigh, while the latter is supported either by 
the arm or across the opposite limb, and the tendon of the patella or of the 
quadriceps femoris is briskly tapped with the edge of the open hand, there 
follows an instantaneous contraction of the extensors, raising the leg. The 
ankle reflex is produced by placing the hand against the sole of the foot and 
flexing the lattei- on the tibia, while the leg is supported on the knee; a 
sudden contraction is experienced. When these movements cannot be elicited 
by the employment of the proper test, the failure is attributable to disease 
located in the cord. 
Again, rigidity and spasmodic contraction of muscles, if accompanied by 
muscular atrophy, point to central rather than to meningeal disease. 
Tumors.-Tumors of the spinal cord or of its membranes are rarely seen, 
and when met with are in most instances connected with the meninges. 
These neoplasms of the medulla spinalis and its membranes are fibrous or 
sarcomatous, and in the course of their growth give rise to symptoms of 
spinal irritation and paralysis. 
Injuries of the Spinal Column. 
Mechanism.-It is impossible properly to appreciate the diseases and in- 
juries of the spinal column without a thorough understanding of the ana- 
tomical construction and the physiological function of this portion of the 
skeleton and of the part of the nervous system which it contains. 
The vertebral column is a pillar of support, a centre about which all the 
movements of the body are executed. To it are attached the ribs and sev- 
eral of the muscles concerned in the mechanism of respiration; from it is 
suspended a considerable part of the digestive tract. In a canal which 
traverses its entire length are placed the medulla spinalis and its mem- 
branes ; and from its sides emerge the nerves, which are distributed to the 
outstanding organs and confer motion and sensibility on the muscles of 
animal and organic life. Every shock communicated to the body must affect 
in some degree this axis of the osseous system and its contents. The neces- INJURIES OF THE SPINAL COLUMN. 
849 
sary requirements of flexibility, solidity, and support have been wonderfully 
produced in the spinal column by a complex association of diverse struc- 
tures. 
The osseous part, instead of consisting of a single cylindrical bone, is made 
up of a number of separate superimposed pieces, each having arches which 
inclose a central opening, these openings forming, when all approximated, 
the spinal canal. Between the bodies of the different vertebrae are interposed 
fibro-cartilaginous cushions, which serve the double purpose of binding the 
bones together and of breaking by their elasticity the vibrations which are 
communicated to the body. Between the laminae of the vertebral arches the 
spaces are filled by yellow elastic membranes (ligamenta subflava), which 
fulfil in this locality, but even more completely, the same requirements. Sub- 
jected as the spinal column must continually be to flexions and twists, both 
voluntary and involuntary, it is necessary that its individual parts should 
be securely bound together: this is accomplished by the seven processes, 
articular and non-articular, possessed by each piece, and which are so dis- 
posed and so locked together by powerful ligaments of white fibrous tissue 
that only a small degree of movement is allowed between any two pieces, 
although in the aggregate it is quite considerable. 
It will be seen also that at those regions of the spinal column where the 
range of movements is greatest, as in the cervical and the lumbar, and where, 
in consequence, the spinal marrow would be most exposed to pressure, the 
canal is largest. To provide a safe way for the passage of the spinal nerves 
from the spinal marrow, each vertebra possesses a notch on the upper and 
lower surfaces of the pedicles at their junction with the body. 
In addition to these marvelous adaptations of structure to function, there 
is developed in connection with the assumption of the erect position a series 
of curves. These not only conduce to grace of movement, but secure, on 
well-known mechanical principles, increased strength, with diminished ex- 
penditure of muscular power, and permit of the transmission of vibrations 
with gradually lessening momentum. 
On opening the spinal canal of the cadaver it will be seen that the cord 
does not fill it, but is suspended in it, attached above at the foramen magnum 
occipitis, and below by the filum terminate, and that its connections or guys, 
laterally, are at the points where the nerves, encased in prolongations of the 
theca, pass out through the intervertebral foramina. Between the cord and 
the walls which inclose it lies a plexus of large, thin-walled veins, supported 
by loose bands of connective tissue and fat. The cord in the adult, more- 
over, when approaching the lower portion of the spinal canal, or at the last 
dorsal vertebra, loses its cylindrical form and is continued on through the 
lumbar and sacral regions-those portions greatly exposed to concussion- 
in the form of a leash of large, firm nerves, enveloped in the theca and other 
membranes of the structure. 
We find, too, that between the pia mater, which closely embraces the cord, 
and the arachnoid membrane, a considerable space exists,-the subarachnoid, 
-which is occupied by fluid, thus furnishing the medulla spinalis the benefit 
of a hydrostatic support, in which it may be said to float. Filling up the 
grooves on either side of the spine, and between the transverse and spinous 
processes, are lodged muscles, with their numerous tendons. 
It may be affirmed of all injuries of the spinal column (as of those of the 
cranium) that their danger must be measured by the damage done to the 
contents,-in this case, the medulla spinalis. 
Sprain,-Considering the number of joints and ligaments possessed by the 
spine, with the violent twists and bends to which they are subjected, it is no 
matter of surprise that the column should be subject to sprains. Along with 
most of these injuries there is more or less muscular damage sustained, either 
by overstretching or by contusion. The portions of the spine which suffer 
most are the lumbar and the cervical,-parts possessing normally the greatest 
vol. ii.-54 850 
SURGICAL DISEASES OF THE SPINAL REGION. 
degree of motion. The determining force may be applied either directly or 
indirectly. 
A butcher, while bending over his block, was struck on the back of the 
neck by a quarter of beef, which fell from the hook on which it had been 
suspended. The momentum and weight of the vulnerating body bent the 
spine and head violently forward, but did not force him to the ground. 
The pain experienced through the muscles of the neck was very severe. He 
was unable to turn his head towards either side, and when desiring to look 
to the right or to the left was able to do so only by turning the whole body 
in the required direction, the head and neck being preserved in a perfectly 
immovable position. The parts in a few moments became swollen and intol- 
erant of pressure. The power of the upper extremities was materially less- 
ened, though sensation was but slightly if at all impaired. In a few days 
a marked induration could be felt deeply imbedded in the muscles on the 
back of the neck, the acute pain subsided into a deep-seated ache, deglutition 
became painful, the back of the scalp felt sore, and at night some heat of skin 
and restlessness indicated a slight febrile disturbance. Here was an instance 
of spinal strain attended with muscular contusion, caused by force directly 
applied. 
A laborer descending a staircase lost his footing and fell, the back of the 
head striking against the wTall at the foot of the landing, the resistance of 
which, opposed to the weight of the body, caused a severe flexion of the cer- 
vical spine. When help reached him, his head was found to be rigidly fixed. 
Any attempt to turn it to either side extorted a cry of suffering. The upper 
extremities were numb and weak, there was a tingling of the ends of the fin- 
gers, and the back of the neck was swollen and sore to pressure, becoming 
much ecchymosed. In the course of four or five days the man recovered the 
power and sensibility of the arms, but the muscular immobility and the dread 
of moving the neck were so great that, when he was asked to flex or extend 
the head, he would place one hand under the chin and the other upon the 
occiput, and thus cautiously make the movement. Any effort to turn the 
head to the right or to the left was preceded by placing a hand on each 
temple and then turning the body along with the head. These symptoms 
gradually passed away. The case was an example of spinal strain caused by 
violence indirectly applied. 
A carpenter, while engaged at his work, was caught between the joists of 
a building and a falling scaffold. While held by the pelvis, the body w'as 
forcibly twisted by the weight of the superincumbent timber. When he was 
extricated from his perilous position, his lower limbs were found to be power- 
less and the sensibility almost entirely lost, the pain in the loins was severe, 
the muscles over the lumbar spine were tendei* and swollen, he wTas unable to 
turn himself in bed, and the urine dribbled from the bladder. In twelve days 
motion and sensibility returned to the limbs, the continence of the bladder 
was restored, and, except weakness and soreness in the muscles of the lumbar 
region, which made any attempt to rise or to sit extremely painful, the effects 
of the injury appeared to have passed away. Here was an example of spinal 
strain produced by the operation of indirect forces acting in opposite direc- 
tions and twisting the spine. These sprains, then, are caused by flexion, by 
extension, and by twist. 
The morbid changes which attend an accident of this nature consist in 
the overtension or the rupture of some fibres of the spinal ligaments. When 
determined by flexion, the ligaments involved are the supra spinous and the 
posterior common vertebral. When the accident follows extension, the liga- 
ment implicated is the anterior common vertebral; when caused by twist, 
the articular ligaments and the vertebral fibro-cartilages suffer chiefly. In 
addition to the damage done to the ligaments, the muscles, blood-vessels, 
nerves, and synovial membranes participate in the injury. 
Contusions of the muscles of the back, when severe, are followed by CONGENITAL DEFECTS OF THE SPINE. 
851 
stiffness and pain on sitting or standing, all movements of the body being 
painful. 
Congenital Defects of the Spine, and their Consequences. 
Arrest of development may occur in this region, as in other parts of the 
body, the symmetrical halves of the spinal column failing to coalesce, leaving 
a gap or chasm between. This separation may extend through the bodies 
of the vertebrae, or, as is more commonly the case, may be restricted to the 
arches and the spinous processes, leaving the spinal canal uncovered by bone. 
These arrests of growth are much more common at the lower than at the 
upper portion of the spine. This is in harmony with the development of 
the arches, which progresses from above downward. Cruveilhier, in his 
"Pathological Anatomy," mentions a case in which the arches were defective 
in the whole length of the spine. About 50 per cent, of all cases of hydro- 
rachis occur in the lumbar region, 12 per cent, in the lumbo-sacral, and 27 
per cent, in the sacral. 
Hydrorachis.-As a consequence of incompleteness in the arches poste- 
riorly, the membranes of the medulla spinalis press through the opening, 
forming a tumor, which is termed hydrorachis, and sometimes, though im- 
properly, spina bifida, the latter term expressing only the vice of conforma- 
tion which gives rise to the disease. 
The common seat of hydrorachis is the lower lumbar (Fig. 1522) or the 
lumbo-sacral region. There are exceptions to this 
rule, the tumor being sometimes seen over the 
sacral, the dorsal, and even the cervical region. 
Exceptionally two or more tumors are present. 
The protrusion occurs during the last months of 
intra-uterine life, and is often found associated with 
other congenital malformations, as hare-lip, cleft 
palate, hydrocephalus, club-fbot, and paralysis of 
the lower extremities, the bladder, and the rectum. 
The formation of a tumor of this nature has oc- 
curred after birth. 
The tumor varies in size from that of a hickory- 
nut to that of the foetal head. The base or attached 
portion is sometimes sessile, at other times pedun- 
culated. 
Anatomy.-The external appearance of the tu- 
mor is not always the same. When the integu- 
ment retains its normal thickness and its adipose 
tissue, the surface of the hydrorachis may differ 
very little from that of the adjacent skin, perhaps 
being a little more corrugated. The cutaneous 
covering is often extremely attenuated, so that the swelling is quite trans- 
lucent, or the integument, like the vertebral arches, may be defective, when 
the surface of the tumor presents a red, raw appearance. Beneath the skin 
are the membranes of the spinal cord blended together to form the sac and 
distended with a limpid or straw-colored fluid. The source of this fluid is 
not always the same. It is either arachnoid or subarachnoid, according as 
it is derived from the cavity of the arachnoid membrane or from the vessels 
of the pia mater or of the cord. 
The subarachnoidean or cerebro-spinal fluid is much the more common. It 
is limpid, of low specific gravity, having a neutral or faintly alkaline reac- 
tion, with perhaps the slightest trace of albumen, and containing some saline 
matters. A substance analogous in its chemical reactions to diabetic or grape 
sugar has also been described. The communication between the fluid of the 
subarachnoidean variety of hydrorachis and that occupying a similar space 
Fig. 1522. 
Hydrorachis. 852 
SVRGICAL DISEASES OF THE SPINAL REGION. 
in the brain has been well established. Pressure on the sac of a hydrorachis 
has been found to produce stupor, from the wave of fluid being forced back 
within the skull. In cases where, conjoined with the spina bifida, there ex- 
isted hydrocephalus, the swelling of the head has been noticeably increased 
by compressing the spinal tumor. 
The relation between the cord, the spinal nerves, and the sac is not always 
the same, but is determined by the location of the fluid, as has been shown 
by Mr. Hewett. 
When the fluid is situated in the cavity of the arachnoid membrane, it 
forces the sac through the defect in the arches and at the same time presses 
the cord forward, so that the latter is in front of the sac. If the fluid con- 
tents of the tumor are cerebro-spinal, or situated beneath the arachnoid 
membrane, and the cord is adherent to the sac, the latter will contain both 
the cord and the nerves, which are forced backward. 
Cases have been observed in which the inner surface of the sac was lined 
by an expansion of the cord and nerves. This condition is believed to be 
due to the fact that the spinal canal, in the early stage of development, ex- 
tends through the entire length of the medulla spinalis, and communicates 
with the fourth ventricle of the brain. The cerebro-spinal fluid gravitating 
to the bottom of this canal expands it in all directions, so as to form a pouch 
of neurine within the sac. The presence of a body like grape sugar and the 
absence of albumen, which are said to distinguish the fluid of hydrorachis, 
are of doubtful diagnostic value. 
Diagnosis.-Tumors are met with over the lumbar or sacral region which 
might be mistaken for hydrorachis, especially cysts, which are occasionally 
seen exactly on the median line. Whether the growth is cystic, fibrous, or 
adipose, there is one important test which will usually serve to establish the 
diagnosis, namely, the existence of a completed arch with its spinous process, 
which can, in tumors other than those arising from the bifid spine, be dis- 
covered underlying the growth. In addition, the tenseness of a hydrorachitic 
enlargement during the crying of the child, and our ability to lessen its size 
by pressure, especially when the patient is turned head downward, will con- 
clusively remove any obscurity which may exist. It has also been suggested 
in doubtful cases, particularly in cystic tumors, to examine the fluid, as that 
of hydrorachis (as already stated) sometimes differs from the liquid contents 
of other cysts. 
Symptoms.-The signs of hydrorachis are an enlargement or tumor, gen- 
erally in the lumbar region, exactly in the median line or in the natural 
position of the spinous process, and around which may be felt the margins of 
the bony opening through which the tumor passes. The tumor, when the 
skin is attenuated, will probably be transparent, and when palpated will com- 
municate the sense of fluctuation. When the child cries, some enlargement 
or tension may be detected in its walls. 
As the growth increases, ulceration not unfrequently follows, which opens 
the sac and allows the contents to escape. Should the child not perish from 
convulsions, the opening may afterwards heal up, or a fistula may remain, 
through which a small amount of fluid will continue to pass. Sometimes the 
sac and skin become so extremely thinned as to permit a certain amount 
of fluid to exhale from the surface, without any actual lesion of the tissues. 
When the tumor contains a portion of the cord or its nerves, the pressure 
resulting from the increased accumulation of fluid in the sac will often induce 
paralysis of the lower extremities, of the bladder, and of the rectum. From 
the same cause convulsions are provoked, and the child dies; and, finally, 
in a very few cases, through the development of the arches, the neck of the 
sac will be gradually encroached upon, until at length its cavity becomes 
entirely disconnected with either the arachnoid or the subarachnoid space, 
when a spontaneous cure follows. 
In a child which I kept under observation for two years at the clinic of 
the University Hospital, I watched with great interest this mode of spon- CONGENITAL DEFECTS OF THE SPINE. 
853 
taneous cure. The tumor gradually diminished in size, and its neck became 
contracted, until, finally, its connection with the body was reduced to the size 
of a small probe. The child grew, and became strong and vigorous. A little 
mass of what appeared to be the redundant integument of an extinct sac was 
all that remained, and this the mother was anxious to have removed. 
As the case appeared to have been perfected for over a year, I was induced 
to clip the thread-like pedicle which connected the shriveled tag of skin to the 
body; to my surprise, I afterwards learned that a serous fluid was flowing 
from the end of the stump. The opening could not have been larger than a 
hair. I directed the medical attendant, Dr. Haynes, to pass a pin through 
the sides of the opening, including a considerable amount of tissue on either 
side, and bring the parts together with a figure-of-eight suture. The opera- 
tion proved successful, and the child made a permanent recovery. 
As a rule, however, children affected with hydrorachis die in five or six 
months after birth. A. few instances have been recorded in medical writings 
in which the subjects of the disease have reached adolescence, and even 
mature manhood. Among the latter is the case of Behrend, of a man who 
reached the age of fifty-one, and anothex* of Moulins, of Bordeaux, who lived 
to thirty-seven.* 
Treatment.-In the large majority of cases of hydrorachis nothing can 
be done towards effecting a cure, and very little in the way of palliation. 
Many of the attempts which have been made by enthusiastic surgeons to 
remove the disease have been ill-timed and contributed to hasten the fatal 
event. It must not be forgotten that when the base of the tumor is sessile, 
and contains, as it generally does, a portion of the spinal cord or its nerves, 
it matters not what plan is adopted, whether the ligature of the growth, as 
suggested by Bell, or puncture and pressure, as practiced by Abernethy and 
Six* Astley Cooper, ox* compression with the clamp, the device of Wilson, of 
England, or injection, the method of the late Dr. Brainard, of Chicago, or 
excision, all must terminate in the same unfortunate manner, precipitating 
death by paralysis or convulsions. 
When the tumor is pedunculated, a form which hydrorachis tends to as- 
sume; when the defect in the posteriox- wall of the spinal canal is small, or 
when the developxnental force continues operative and the arches grow to- 
wards each other, thus encroaching on the mouth of the sac, there is often 
a tendency to a spontaneous cure; and if the neck of the tumor continues to 
lessen, there is some reason to believe that it is largely liquid and contains 
no very important nerve-trunks. 
These are the cases which tempt the surgeon; but, though the most inviting, 
even in them the operation is by no means devoid of danger. 
A safe plan of procedure in all such cases is to have the child carefully 
watched, and, as long as the natural process of pedunculation is progressing, 
to refrain from active interference. Should this process become stationary, 
and the health of the child continue undisturbed, I should still abstain from 
any operation. If, however, the tumor enlarges and general symptoms arise 
of a threatening nature, an operation is not to be declined. 
The indication is to obliterate the communication between the sac and the 
spinal canal; and the plan which commends itself as the most favorable, both 
from its simplicity and its occasional effectiveness, is the injectioxx of the sac 
with tincture of iodine. Brainard, who introduced the practice, claims to 
have cured three cases out of seven,-a success, I may remark, which no one 
since has obtained. 
In using the injection, in sessile tumors, an indirect sxxbcutaneous puncture 
of the sac should be made with a delicate trocar, which is thrust through 
the sound skin adjacent to the tumor. After drawing off about one-half of 
the fluid, leaving enough to maintain a sufficient degree of pressure on the 
spinal cord to prevent convulsions, an injection should be thrown into the 
sac varying in strength according to the form of the tumor, whether pedun- 
* Bulletin de la Society de Chirurgie, 1860. 854 
SURGICAL DISEASES OF THE SPINAL REGION. 
culated or sessile. For the latter it should consist of one grain and a half 
of iodide of potassium and one-fourth of a grain of iodine to the ounce of 
distilled water; in the case of a pedunculated tumor, fifteen grains of the 
iodide of potassium and five grains of iodine to the same quantity of water. 
The canula should then be withdrawn and the puncture in the skin covered 
with a strip of adhesive plaster. When the tumor is pedunculated, its con- 
tents are to be entirely removed, and, after injecting the sac and allowing 
the fluid to run out, it should be partially refilled with the cerebro-spinal 
fluid first drawn, which is to be preserved for the purpose at a proper tem- 
perature, or with distilled water. During the injection the neck of the sac 
should be compressed, in order to prevent the iodine from entering the spinal 
canal. If the operation results favorably, the inflammation which is developed 
in the sac will close the communication at the neck of the tumor, between its 
cavity and that of the spine, and thus cure the disease. When the method 
of injection is resolved on, it should, in my judgment, be confined to cases of 
pedunculated hydrorachis. 
General Phenomena following Spinal Injuries. 
In consequence of the relation which the spinal marrow, through its nerves, 
sustains to almost every portion of the body, the phenomena which follow' its 
injuries are no less remarkable for number than for variety. It will be proper, 
therefore, to present a general resume of the different morbid effects which fol- 
low spinal traumatism. These vary according to the particular region involved. 
Paralysis.-Thirty-one pairs of nerves make their exit from the cord 
through the intervertebral foramina, conferring on the muscles of animal 
life motion and sensation. Consequently, paralysis is one of the most con- 
stant phenomena following severe injuries to the spine. This paralysis may 
be motor, sensory, or moto-sensory, the latter being most common. Al- 
though in most cases of severe injury of the spinal centres motion and sen- 
sation are alike lessened or destroyed, indicating that the lesion has affected 
the entire segment of the cord, yet there are instances in which the loss of 
one function alone occurs, or in which the two are very unequally affected. 
The explanation of such accidents, now that we understand the anatomy 
and physiology of the medulla spinalis, is simple, as they indicate that the 
damage is limited to one column more than to the other. The paralysis 
usually extends to all that portion of the body below the seat of injury, 
or, rather, to all the muscles which receive their nerves from the section of 
the cord implicated. One portion of a limb or one group of muscles may 
be paralyzed while the others retain their movements. Bilateral paralysis 
is the rule, unilateral the exception, after injury of the spine. When the loss 
of power is one-sided, it implies that the lesion affects only one lateral half of 
the cord. Though the paralysis affects usually only those parts below the seat 
of damage to the cord, there is a possibility that loss of power may extend 
somewhat to portions of the body above. When this is the case, the paralysis 
is always secondary, and is due to inflammatory changes or to hemorrhages 
in the medulla spinalis. 
To formulate with more detail the phenomena following injuries of the spinal 
cord, they are best presented on a physiological basis, as observed By Brodie. 
In paralysis of the bladder there is first retention, often followed by in- 
continence of urine. The urine undergoes a change, becomes strongly alka- 
line, dark-colored, and loaded with mucus, pus, and phosphates. It decom- 
poses, emits a highly offensive odor, and becomes a violent irritant to the 
mucous membrane of the bladder, developing at length a serious cystitis, and 
occasionally even sloughing of the mucous membrane. It is often increased 
in quantity, sometimes diminished, but rarely entirely suppressed. Blood in 
the urine is common after spinal injuries, but it is to be attributed more to 
renal concussion than to the violence applied to the spine. Sometimes, after 
vesical paralysis, there is seen a singular instability in the chemical reaction GENERAL PHENOMENA FOLLOWING SPINAL INJURIES. 
855 
of the urine, which is one day alkaline and the next day acid. It may be 
diabetic when the injury involves the cervical part of the cord. 
As the muscular walls of the abdomen and of the intestines receive their 
nerves from the lumbar portion of the medulla spinalis, both are liable to 
suffer: hence the flaccid and insensible state of the first, and the gaseous dis- 
tention of the latter, which follow accidents to this part of the spine. 
When the lumbar section of the spine is involved, the paralytic effects 
are not uniform, inasmuch as the cord proper terminates about the second 
vertebra of this region, the remainder of the canal being occupied by the 
cauda equina, the nerves of which are not likely to participate in an injury. 
While, therefore, paraplegia may occur, the loss of power often affects merely 
the continence of the bladder or the bowel, or one or two groups of muscles 
below. 
As we ascend the vertebral column through the dorsal and cervical regions, 
we find, with each segment of the cord injured in the ascent, an additional 
number of muscles deprived of power, as the abdominal, the thoracic, and 
those distributed to the upper extremities, until at length, when the lesion 
occurs above the fourth cervical vertebra, death follows suddenly, in con- 
sequence of the nervous communication between the diaphragm and the 
phrenic nerve being interrupted. 
Hypercesthesia.-Though loss of sensation is a common accompaniment of 
motor paralysis, there may exist an unusually exalted state of sensation, 
-hyperresthesia. There may be motor and sensory paralysis on one side 
and hypenesthesia on the other. There is in such cases probably a slight 
degree of injury to the posterior column of the cord, or to the roots of 
those nerves that leave that portion of the cord which supplies the super- 
sensitive district. The suffering which accompanies this condition is often 
excruciating when the part is touched, and the surface of the hypersesthetic 
region frequently presents a red or mottled color, and a glossy, shining, oi- 
polished appearance. 
Pain.-Among other phenomena, pain is frequently witnessed. It is ex- 
perienced sometimes at the injured part of the cord, and at other times at 
points remote from this centre, in a particular group of muscles, in the fin- 
gers or the toes. The character of the pain varies, the shades of distinction 
being expressed by the terms burning, pricking, tingling, scalding, darting, 
twisting, and constricting, or cord-like. 
Muscular system.-When the pressure or lesion is not adequate to produce 
paralysis, the effects on the muscular system are often very striking. These 
are manifested sometimes in twitchings, in irregular or spasmodic movements 
of certain muscles, in general convulsions, or in a persistent rigid contraction 
of one or more muscles. Though they are supposed to have some diagnostic 
significance as indicating spinal compression, I am not prepared to believe 
that the connection between the two is sufficiently uniform to constitute a 
reliable basis for any such conclusion. As signs of meningitis and of myelitis, 
they are, however, not without value. 
Elevation of temperature.-An increase of temperature in the paralyzed 
parts is another effect. It is more pronounced when the cervical portion of 
the cord has been injured, probably from the relation which this part of the 
spinal centre holds to the sympathetic nerve. Experiments in the ther- 
mometry of paralyzed limbs, made by Brodie, Hutchinson, and others, show 
an increase of temperature, amounting to from two to eight degrees. This 
phenomenon must be referred to the loss of that regulating power over 
the walls of the vessels which is possessed by the vaso-motor system of 
nerves, in consequence of which the paralyzed parts become overcharged 
with blood. The local heat is subjected to alternations, rising and falling 
with a kind of periodicity, though when such fluctuations are observed the 
paralysis is not complete. A constantly high temperature foreshadows 
danger in the near future. The degree of actual heat may be in striking- 
contrast with the sensations of the patient, which are often those of cold. 856 
SURGICAL DISEASES OF THE SPINAL REGION: 
Eye and lachrymal gland.-When the cervical part of the medulla spinalis 
has been damaged, certain symptoms appear which belong peculiarly to this 
part of the cord, and which are due to paralysis, more or less complete, of 
the sympathetic nerve, between which and the spinal system communication 
is established through its cervico-cephalic branch. The symptoms originally 
noticed by Brodie, and subsequently by Brown-Sequard and others, consist in 
lachrymation, contraction of the pupils, flushed face, redness of the conjunc- 
tiva, sometimes strabismus, and an increase of vital heat. These signs, in- 
dicating as they do extensive damage to the cord, are to be accepted as of 
the most serious character. 
Dyspncea.-This symptom will attend injuries of the cord in the dorsal or 
in the cervical region, as from both of these the muscles concerned in respi- 
ration receive their nerve-endowments. From the dorsal portion are de- 
rived the intercostal nerves, which supply the intercostal muscles, and also 
branches distributed to the serrati muscles; and from the cervical division 
of the medulla come the long thoracic and phrenic nerves, which supply 
the great serrati muscles and the diaphragm. The difficulty of respiration 
will, therefore, be increased in proportion to the height at which the injury 
implicates the cord. The occurrence of dyspncea as a secondary effect of 
spinal injury is an extremely unfavorable sign, betokening, as it does, central 
changes of an incurable character, as inflammatory softening of the cord. 
In these distressing cases of embarrassed respiration the difficulty is in- 
creased by the intestines becoming distended with air and pressing upward 
against the diaphragm. 
Genital organs.-Priapism is the most noteworthy symptom observed under 
this head after lesion of the spinal cord. It is entirely independent of the 
will, and is neither produced by nor attended with any voluptuous sensation. 
It may be occasional or continuous, and is generally to be interpreted as an 
unfavorable sign, indicating hemorrhage into the cord ; though I have wit- 
nessed this condition where the cord had received no serious damage, the 
patients entirely recovering. Priapism is most commonly seen after injury 
to the cervical part of the cord, though the symptom has occurred in patients 
in whom the lesion was located in the dorsal or in the lumbar region. It 
is among the phenomena commonly observed in the execution of criminals 
by hanging. 
Even in moto-sensory paralysis, priapism, as was first pointed out by Mc- 
Cartney, can be excited by mechanical or reflex irritation, as the introduc- 
tion of the catheter. Hilton, in order to explain priapism following lesions 
of the spinal cord, refers the condition to the deprivation of that portion of 
the medulla spinalis below the injury, of the inhibitive power possessed by 
the brain over the excito-motor phenomena of the genital organs. 
Circulatory system.-Injuries to the upper dorsal and lower cervical portions 
of the cord, in virtue of the connection which exists between the cervical 
and the dorsal ganglia of the sympathetic nerve, produce well-marked im- 
pressions on the heart, which are indicated by retardation of its action. The 
vessels of the pericardium become overdistended with blood to a degree 
which may cause a free transudation of serum. Hyperaemia occurs at all 
points which have become paralyzed. The vessels, especially the deeper 
ones, are not only surcharged with blood, but the circulation moves more 
sluggishly through them' in consequence of the vaso-motor paralysis which 
accompanies the paralysis of the voluntary muscles. 
It is the absence of an active capillary circulation and the fixedness of 
position necessitated by the deprivation of sensation and motion, which, in 
paralysis, leave those portions of the body and of the extremities subjected 
to pressure so prone to suffer from bed-sores. 
Deglutition.-Difficulty in swallowing is also an attendant of spinal injuries 
when seated high in the cervical region, the disturbance to the function 
being the result of involvement of the glosso-pharyngeal and pneumogastric 
nerves; and it is probably in consequence of communications of the last- GENERAL PHENOMENA FOLLOWING SPINAL INJURIES. 
857 
named nerve with the cord that jaundice sometimes follows injuries to the 
dorsal region of the spine, and that distressing vomiting results from acci- 
dents to the cervical part of the cord. 
Effect on nutrition.-Two causes operate to disturb the nutrition of a para- 
lyzed part, namely, the absence of motion and the want of a sufficiently 
active interchange of materials between the blood and the components of the 
tissues concerned. Hence we have wasting of the muscles, disappearance of 
the fat, roughness of the skin, extensive epithelial desquamation, arrest in 
the growth of the nails, emaciation, rigidity of the articulations, and, not un- 
commonly, vicious contractions of the limbs. It is true that there are many 
exceptions to the wasting of paralyzed parts. Very often this feature is as 
noticeable in the pseudo-paralysis of hysteria as in that which is real, occa- 
sioned, it is thought, by the fact that true paralytics are always making 
efforts to move the disabled muscles, the stimulus of which is supposed to 
contribute to their nutrition, while in paralysis from emotional causes this is 
not attempted. I doubt very much the correctness of this explanation, how- 
ever, and believe we must seek for the true cause in such degenerations of the 
medulla spinalis as render the cord incapable of receiving reflex impressions or 
such destruction of the nerves as to make the transmission of any influence, 
sensory or motor, impossible. In support of this view may be adduced the 
fact that the absence of atrophy is far more common in hemiplegia than in 
paraplegia, the decussation of nerve-fibres rendering the supply of some vol- 
untary nervous energy still possible to the affected muscles of the hemiplegic. 
The blood itself is not exempt from morbid changes. A young lady whom 
I visited in connection with Dr. James Darrach, of Germantown, had, six 
months previously, fallen several times while engaged in skating, striking 
on the nates and the sacrum. Though at the time of these several accidents 
she was conscious of being hurt, the injuries were not sufficiently severe to 
induce her to abandon the amusement, until, finally, pain across the hips and 
weakness of the lower limbs compelled her to relinquish this, and at length 
almost every other kind of exercise. When I saw her, the body and limbs 
were emaciated, and the skin was rough like the surface of a nutmeg-grater. 
When she walked across the floor it was with a rocking, side-to-side move- 
ment, the extensors possessing very little power. Numerous subcutaneous 
patches of extravasated blood were seen, particularly over the legs, and she 
was bleeding freely from the gums. Previously she had suffered from ob- 
stinate vomiting. Death occurred two weeks after my visit, but no autopsy 
was allowed. 
Cerebral symptoms have been described as the result of spinal injuries, as 
headache, delirium, insomnia, loss of memory, irascibility, etc. These, when 
present, must be classed as secondary manifestations, either developed in 
consequence of an extension of meningeal inflammation to the brain, or due 
to the skull suffering in common with the spine from the vulnerating force. 
Diagnosis.-The affections with which the secondary effects of spinal in- 
juries may be confounded are hysteria, rheumatism, and concussion of the 
brain. From hysteria the following considerations will be sufficient to estab- 
lish the distinction: 
HYSTERIA. 
A disease of women. 
Emotional element dominant from the first. 
An affection, generally, of the young. 
Paroxysms of suffering irregular and intermit 
tent. 
Sensibility of the surface exaggerated. 
Never ending in paralysis. 
SPINAL DISEASE. 
Not confined to either sex. 
Secondary, and only after a considerable time 
has elapsed between the accident and the morbid 
symptoms. 
Peculiar to no age. 
Continuous or progressive. 
Very little increase of sensibility, if any. 
Often ending in paralysis. 
Rheumatism possesses many peculiarities in common with the secondary 
phenomena attending traumatic disease of the spinal cord or its membranes. 858 
SURGICAL DISEASES OF THE SPINAL REGION. 
In both there are pain, stiffness, and undue sensibility along the course of the 
spine, with muscular disability; but a careful inquiry will succeed in detecting 
points of difference. They may be arranged as follows: 
RHEUMATISM. 
Not necessarily preceded by any injury. 
Pain, uneasiness, soreness, and stiffness local. 
Attacks sudden and non-progressive in severity. 
In motion pain is referred to a particular point. 
Indisposition to muscular motion, due to the 
pain and uneasiness produced. 
Often accompanied with rheumatism of other 
articulations. 
No eccentric sensations. 
Often a rheumatic history. 
Urine loaded with urates. 
EFFECTS OF SPINAL INJURIES. 
Always a history of such injury. 
Not local, but diffused, or at several distinct 
points at the same time. 
Attacks slow and progressive. 
General rather than confined to a small area. 
Same symptom due to inability, the result of 
diminished power or of paralysis. 
No concomitant articular disease. 
Tingling, creeping, and burning sensations in 
the cutaneous nerves. 
No such history except as a coincidence. 
Urine containing phosphates, particularly of 
lime. 
The differential diagnosis between the secondary effects of cerebral con- 
cussions and injuries of the spinal cord must be based on the previous history 
of the case, and on the nature and locality of the symptoms. In both there 
may be muscular weakness and spasms, paralysis of the sphincters, and 
psychological phenomena. Contrast the following points: 
CEREBRAL CONCUSSION. 
Force usually received on the head. 
Pain or uneasiness in the head primarily. 
Any distortions or paralysis of the muscles 
which may ensue are preceded by head-symptoms, 
as cephalalgia, irritability of temper, or insomnia. 
Pain, rigidity, and abnormal sensibility of the 
spine on movement or pressure sometimes but not 
invariably present. 
SECONDARY EFFECT OF TRAUMATIC IN- 
JURY OF THE SPINAL CORD. 
Force usually applied more directly to the spine. 
In the course of the spine. 
No such sequence of symptoms. 
All of these symptoms usually experienced. 
Should cerebral and spinal symptoms coexist, as is sometimes the case 
when force of unusual severity has been applied to the body, either at the 
cranial or at the sacral extremity, it will be impossible to calculate the symp- 
tomatic proportion due to each, though, reasoning from the greater vul- 
nerability of the brain, when the skull has received the first impact of the 
violence it will be fair to infer that the cerebral factor is the dominant one. 
Prognosis.-In no class of injuries is the prognosis so unfavorable as in 
those which follow lesions of the spinal cord. Death may be instantaneous, 
particularly when the lesion involves the cervical portion of the cord ; or it 
may follow a protracted invalidism, which wears the sufferer out by compli- 
cations arising in the progress of the case. The causes of death from all 
kinds of spinal injury are shock, asphyxia, cystitis, meningitis, myelitis, dis- 
ease of the brain, and bed-sores or sloughing. In the few cases of recovery 
after spinal injury, accompanied by paralysis, the improvement has been 
very slow. 
Treatment.-In the early stage of all spinal injuries involving the cord, 
nothing exceeds in importance rest. In the absence of paralysis, or when 
the muscular weakness is only slightly present, and when hemorrhage or in- 
flammatory consequences are apprehended, the prone position advocated by 
Mr. Erichsen in concussion of the spine is to be preferred for a time, though 
it is one which is difficult to maintain for any protracted period. The pos- 
ture is one which brings to our aid a valuable adjuvant in the treatment 
either of hemorrhage or of inflammatory determination, namely, that of 
gravitation. Cups may be applied along both sides of the spine, first wet, and 
subsequently dry, and, if the temperature rises, an ice-bag can be advanta- 
geously placed over the same region. CURVATURES OF THE SPINE. 
859 
When paralysis follows the injury, the procuring of a water-bed is of the 
utmost moment. The dorsal position now becomes necessary, and the pre- 
vention of bed-sores, even w'ith every precaution, is not always possible. 
When a hydrostatic bed cannot be commanded, a firm hair mattress is to be 
preferred to one made of softer materials, and sloughing is to be guarded 
against by daily frictions of the salient parts of the body with alcohol, and 
by using pads and rubber air-cushions, by which the pressure can be shifted 
to other parts. 
The condition of the bladder will demand early attention, as often the 
viscus is unable to get rid of its contents, and will require catheterization at 
stated periods, usually three times during the twenty-four hours. Only by 
faithfully discharging this duty can the evils of cystitis be prevented. The 
soft gum Mercier catheter is the proper instrument to be used, and, with 
a little instruction, the operation may be safely intrusted to an attendant. 
The bowels are to be kept open, when a spontaneous evacuation does not take 
place, by stimulating enemata, and the utmost attention must be given to 
cleanliness of bed-clothing and of the person of the patient, that excoriations 
and sores may be avoided. When there is reason to suspect the existence of 
meningitis or myelitis, the local abstraction of blood by 
cups will be indicated, and the administration of altera- 
tive doses of mercury, preferably the bichloride, which 
can be continued for a longer time than calomel without 
causing salivation. 
After the acute symptoms have passed over and 
there remains only the paralysis, the use of tonics, with 
some stimulation of the spinal centre, may be very 
cautiously attempted. For the above objects quinine, 
iron, and strychnine constitute the best combination; 
but the closest supervision will be necessary for a time, 
to see that no aggravation of the symptoms follows, 
which is likely to be the case in the event of any intra- 
spinal inflammation still lingering about the damaged 
parts. 
To prevent the wasting of the muscles and to pre- 
serve the skin in a healthy state, resort should be had 
to the judicious use of "massage" and systematic move- 
ments of the paralyzed parts. Should the patient 
so far recover the use of the limbs as to be able to 
stand or to walk about, the application of a plaster 
bandage or of a leather splint to the spine will mate- 
rially contribute to the power both of support and of 
motion. 
Fig. 1523. 
Curvatures of the Spine. 
Anatomical peculiarities.-The natural curves of the 
spinal column are all antero-posterior, with a very 
slight lateral one at the upper part of the dorsal re- 
gion, which is thought to be due to the influence of 
causes connected with the very general use of the 
right hand. The antero-posterior curves are alter- 
nately arranged as follows: in the lumbar region the 
concavity is posterior and the convexity anterior; in 
the dorsal region the concavity is anterior and the 
convexity posterior; while in the cervical portion of 
the spine the disposition of the curves is the same, 
as in the lumbar, namely, concave behind and convex 
in front. (Fig. 1523.) These curves are produced partly by the increased 
vertical extent of the bodies of the individual vertebrae, and partly by the 
intervertebral cartilages. 
Curves of the vertebral 
column. 860 
SURGICAL DISEASES OF THE SPINAL REGION. 
All of the spinous processes of the cervical vertebrae have a horizontal 
relation to the bodies of the vertebrae, and that of the seventh is so long as 
to have received the name of vertebra prominens. Those of the lumbar region 
are similarly disposed, while those of the dorsal division of the column are 
bent downward or imbricated, one overlapping the other. Throughout all 
the region of the vertebral column the spinous processes are accurately in 
line. 
Along either side of the spine are lodged powerful muscles, the tendons of 
which are inserted into the lever-like processes of the vertebrae. These not 
only serve to preserve the erect position of the body, but also, by exerting 
an equally-balanced traction on the spine, keep it from inclining to the one 
side or the other. 
The above anatomical and physiological facts will materially aid the phy- 
sician in the diagnosis of spinal curvatures. 
There are three curvatures observed in the spine, namely, lateral, antero- 
posterior, and rotatory, the last being induced by changes resulting from the 
two other conditions. 
Curvatures of the spinal column are the result of causes quite dissimilar 
in their nature. Those generally concerned in causing the abnormal devia- 
tion are, first, unequal exercise of muscular power on the two sides of the 
column ; second, occupations ; third, alterations in other parts of the skeleton 
demanding spinal compensation ; fourth, structural changes in the vertebrae, 
in their cartilages, or in both. 
Lateral Curvature. 
Lateral curvatures are seen both in the young and in adults. Among the 
first class the chief subjects of the deformity are girls, and occasionally boys, 
between the ages of eight and fifteen. 
The curvature is sometimes in the lumbar and sometimes in the dorsal 
region. Coincidently with the primary, which may be called the pathological 
curve, there are formed two others, which are compensatory, and grow out 
of the necessity foi' maintaining the erect position. Thus, if the primary or 
pathological curve is in the lumbar region and directed to the left side, the 
compensatory one will form in the dorsal region and be 
in the opposite direction, or to the right side, while this, 
in turn, begets the necessity for a third in the cervical 
region, to restore the line of support, imparting a serpen- 
tine appearance to the column as a whole. (Fig. 1524.) 
In marked cases of deviation of the spine there is also a 
rotatory curvature, produced, in my opinion, by the con- 
traction and shortening of those slips of the longissimus 
dorsi and sacro-lumbalis muscles which are inserted on 
the angles of the ribs and the transverse processes of the 
lumbar and dorsal vertebra). This rotatory curvature 
may become so great that the angles of the ribs and the 
transverse processes of the vertebrae, being carried back- 
ward, will finally occupy almost accurately the normal 
position of the spinous processes. 
When the curve previously affects the dorsal region 
of the spine, it has been supposed by Professor Sayre that 
the rotatory precedes the lateral deviation, the serratus 
magnus muscle being the chief factor in causing.the de- 
formity. Whether this is the initial stage or not, there 
can be no doubt in regard to the influence of the above- 
named muscle in the production of the deformity, as its 
oblique position on the side of the thorax and its connec- 
tion with the spine through the rhomboid muscle, making it practically a 
digastric muscle, are highly favorable to such a result. 
Fig. 1524. 
Primary and secondary 
lateral curvatures. LA TER A L CUR VA TURE. 
861 
Lateral curvatures begin most frequently in the dorsal region, preferably 
in its upper part and on the right side. Why this predilection for the right 
side exists it is difficult to explain, unless there is in the curve natural to this 
side a determining influence, which seems to me probable. 
Causes.-The causes of lateral curvature are various. Of course, some 
advantage gained by the muscles of one side over those of the other side is 
immediately concerned in causing the deviation, but what it is which confers 
this advantage-that is, the remote cause-is not always easily ascertained. 
A general weakness of the muscles or of the system at large certainly does 
not enter exclusively into the causation. Weak, delicate girls and boys are 
not more frequently the subjects of spinal curvatures than the strong, mus- 
cular, and robust. 
1st. I am disposed to think that the partial or unequal use of the muscular 
system is most commonly concerned in developing lateral spinal curvatures. 
The boy or the girl freed from the artificial restraints of society, and left to 
follow without check the multitudinous versatility of romp, play, and amuse- 
ment, which are natural and instinctive to young life, rarely, in my ob- 
servation, suffers from a distorted spine. Contrast with this child of liberty, 
whom we will adopt as a type, one who is constantly being instructed in the 
school of Procrustean proprieties, who must walk after a particular fashion, 
carry the head and the pelvis in a prescribed manner, sit for nine hours out 
of the twenty-four at study, either at home or at a desk at school, without, 
in all probability, any support whatever for the back; who in going to and 
from school carries, almost invariably on one side, a formidable number of 
books, who has a minimum of fresh out-door air, and whose only amusements 
consist in dancing and the use of grace-hoops, and you have a subject ad- 
mirably adapted to become the prey, among other infirmities, of the muscular 
disability under consideration. 
The same effect may be produced by the exactions incident to the other 
extreme of the social body. The factory-slave, doomed often to the standing 
position for many consecutive hours in a close atmosphere loaded with foreign 
matter, obliged to take hurried meals, frequently less nutritious than they 
should be, is in danger of drawing too largely on the capacity of the spinal 
muscles, and, by destroying the equilibrium of support, causing the column 
to deviate from the proper line. To social influences, therefore, I attribute 
a very large proportion of all cases of lateral spinal curvatures. It is the 
city, not the country, which swells the ranks of spinal deformity. 
2d. Unilateral muscular atrophy, allowing the spine to deviate from the 
perpendicular, may be the result either of peripheral or of central causes. 
Among the former are to be enumerated blows and sprains, in consequence 
of which the nutrition of the injured muscles becomes so impaired that 
wasting follows. 
Central atrophy of the spinal muscles is more common than is generally 
supposed. Here the seat of the trouble is in the spinal cord, and has the same 
pathological significance as infantile paralysis. The wasting is gradual, and 
often supervenes on an attack of some disease of childhood, as diphtheria, 
whooping-cough, or convulsions. 
3d. Unilateral muscular hypertrophy. - The muscles on one side of the 
spine may, in consequence of certain occupations, become more' developed 
than those of the opposite side, and consequently draw the column in the 
direction of superior power. Adults generally furnish examples of this vari- 
ety of curvature, and among these, blacksmiths, tailors, and sewing-women 
are the persons most affected. A habitual careless position of the body will 
conduce to similar deformity. 
4th. Muscular spasm.-Occasionally one or more of the muscles on one 
side are seen to be in a state of permanent contraction, the effect of which is 
ultimately to bring about a lateral inclination of the column. This condition 
may properly be referred to a central cause located in the spinal cord, and 
in this respect is similar to that contraction which is often seen in torticollis. 862 
SURGICAL DISEASES OF THE SPINAL REGION. 
5th. Rachitis, affecting as it does the structure of bones, and depriving 
them of the resistive power necessary to withstand the conjoined effects of 
pressure and muscular contraction, frequent in childhood, produces lateral 
curvatures of the spine, in common with similar distortions of other bones 
of the skeleton. 
6th. Alterations in the length of one of the extremities.-Whatever produces 
shortening of one of the lower extremities is followed by a tilting of the 
pelvis in the opposite direction, and this in turn by a compensating lateral 
curve in the spine, in order to preserve the line of gravity. Thus, in cox- 
algia and after excisions of the knee-joint we find this change. In like 
manner, after amputations of the arm high up, or at the shoulder-joint, a 
curve gradually forms in the spinal column from the superior weight of the 
opposite side. 
7th. Morbid growths of the sides of the body or pelvis, as encephaloid 
sarcoma or enchondroma, often attain an enormous bulk, and, by the drag 
they exert, call into activity the same movements which conspire to resist 
the effects of pelvic obliquities and which produce compensatory curves of 
the spine. 
8th. Sacro-iliac disease is also liable to cause lateral curvature, from the 
habit which the patient acquires of leaning away from the affected side, in 
order to obtain relief from suffering by the extension produced by the weight 
of the suspended limb. 
In addition to the above causes of lateral spinal curvature, there are de- 
fects in the development of individual pieces of the vertebral column, as 
irregularity of size and undue obliquity of articulating surface, which neu- 
tralize the proper action of the muscles. Similai* effects may be induced by 
rheumatism of the lumbo-dorsal muscles, destroying their proper bilateral 
antagonism. 
Symptoms.-The signs of lateral curvature are both local and constitu- 
tional. When the curve is dorso-lumbar, including the lumbar part of the 
spine and probably the lower third of the dorsal, there are seen, in well- 
pronounced cases, two prominences, one on each side. The one on the con- 
vex side of the curve is muscular, and caused by the stretching of the spinal 
muscle over the salient transverse processes; the other, or that on the con- 
cave side, is bony, and formed by the crest of the ilium, which is rendered 
unusually conspicuous by the sinking in of the abdominal parietes above. 
As all the vertebrae within the limits of the curve move together, it is not 
likely that there will be any marked deviation in the relations of the spinous 
processes to one another. 
When the curve is limited chiefly to the dorsal region, the lateral devia- 
tion of the spinous processes from the line of those belonging to the concealed 
lumbar portion of the spine may be felt, but not seen; the muscles over 
the convexity of the curve are prominent, as also are the corresponding 
scapula, and, in -well-marked cases, the angles of the ribs of the same side. 
On the concave side of the curve the muscles are flattened and sunken, and 
the angles of the ribs have receded from the surface, in consequence of the 
accompanying rotation of the spine. The shoulder of the same side will be 
observed to be lower than its fellow. This inequality in the level of the 
shoulders and the undue prominence of one of the scapulae is often the first 
sign of the disease detected. (Fig. 1525.) A boy complains of one of his 
suspenders constantly slipping off the shoulder, or a girl of her inability to 
keep the shoulder-straps of her dress in place. This should attract attention 
at once to the spine, as it often indicates the beginning of spinal curvature. 
When the pathological or primary cause calls into existence the compen- 
satory or secondary curves, and the lateral are well distributed, the deform- 
ity of the body is less noticeable, notwithstanding the serpentine or undu- 
lating form of the column, as the two extremes of the column, the occipital 
and the pelvic, are in line, though the centre of gravity passes through the 
concavities of the curves instead of their summits, as in the normal spine. LATERAL CURVATURE. 
863 
The prominences of the dorsal spinous processes are greatly lessened, or may 
entirely disappear, and the back may be markedly flattened. If the curves are 
well marked, the effects will be seen also 
in the conformation of the anterior part 
of the thorax, the left breast being more 
prominent, in conformity with the pre- 
vailing frequency of right-sided curva- 
ture, and directed somewhat to the left 
side by the spinal rotation. If the dis- 
ease proves progressive, and is left to 
itself, a time comes when these curves 
are very unequally increased, and, conse- 
quently, all the characteristic deformities 
become more and more conspicuous. 
In slight cases of lateral spinal cur- 
vature the general health may not be 
materially affected, but in more marked 
cases the patient frequently complains 
of muscular weakness, being tired on 
taking exercise, and disposed to seek 
relief by lying or sitting down. Palpi- 
tation of the heart, shortness of breath, 
and disturbances of the digestive organs 
are also not uncommon accompaniments 
of the distortion. 
Structural Alterations.-If we take 
a spinal column in the recent state, 
with its ligaments and cartilages intact, 
and forcibly bend it laterally, it will be 
seen that the effects of such force will be expended, chiefly on the inter- 
vertebral disks of cartilage and on the articulatory processes. Both arc com- 
pressed on the concave side of the curve, while on the convex side the car- 
tilages, being relieved from pressure, become expanded, and the ligaments of 
the articulations become tense. This is just what occurs in lateral curvature, 
and the effect of such pressure and stretching constantly acting on these 
living structures is to cause the absorption of both cartilages and vertebra? 
on the concave side of the curve, as also of the articulating facets of the 
transverse processes. The latter, as shown by Mr. Alexander Shaw, being 
soft in early life, suffer in a very marked degree, and, as their articulatory 
surfaces slope downward and backward, the mechanism concerned in the 
rotatory displacement of the column becomes apparent. With the absorp- 
tion of the cartilages, bodies, and articulating processes on one side, there is 
an elongation of the articular ligaments of the opposite side, which allows 
of both lateral and rotatory curvature. 
In addition to these changes, the lateral flexion and horizontal rotation of 
the vertebrae necessarily produce a change in the position and form of the 
transverse processes, which become on the convex side of the curve unduly 
prominent along the outer margin of the erector spinse muscles and abnor- 
mally separated from one another. The traction to which they are subjected 
on this side is sufficient to cause them to assume a curved shape, while on the 
opposite or concave side they may be found flattened from being crowded 
together. In like manner the ribs on the concave side are in contact with 
one another, or even overlap, obliterating the intercostal spaces, while on the 
opposite side they are separated from one another. (Fig. 1526.) The effect 
of these distortions, especially on the contents of the thorax, is to cause 
considerable displacement of the heart, lungs, and other components of the 
cavity, and to affect in some degree their functions; hence the palpitation 
and shortness of breath often witnessed in cases of this nature. The nerves 
which emerge through the intervertebral foramina on the concave side of the 
Fig. 1525. 
Lateral curvature of the spine. 864 
SURGICAL DISEASES OF THE SPINAL REGION. 
lateral curve participate in the evil effects of pressure, and as the nutrition 
of the muscles on the same side depends largely on the integrity of these 
Fig. 1526. 
Structural alterations induced by lateral curvature. 
nerve-trunks, especially the motor, we find muscular weakness and atrophy 
keeping pace with each other, often accompanied with flatulence, from a 
similar loss of power in the muscles of the intestines, which are energized 
from the same source. 
Treatment.-The treatment of lateral curvature is both constitutional 
and local. Without the former the latter will often prove of little avail. 
Constitutional Treatment.-Every hygienic surrounding should be made 
to conduce to the improvement of the general strength of the body. Fresh 
air, less restraint, less study, a less sedentary life, entire freedom of the body 
from the constriction of clothing, bathing, abundance of sleep, periodical rest 
in the recumbent position, and, where the patient is feeble, with little or 
capricious appetite, tonics, as cod-liver oil, iron, and the phosphates, will be 
demanded; 
In very young children, confinement on the back, in which position they 
can be carried out in the open air by the nurse, will be required until the 
muscles acquire additional strength; and during this period of recumbency 
they can be materially invigorated by systematic " massage." 
Local Treatment.-Too often we find physicians, on the first appearance 
of the deformity, flying to instrumental applications to correct or to prop up 
the spine. Nothing can be more unphilosophical or injurious. The moment 
the trunk is encased in jackets, corsets, or any of the various other con- 
trivances of steel and leather which figure in the books, keeping the muscles 
in a state of rest, these important levers, on which our hopes of improve- 
ment or of cure concentrate, begin to wyaste, and become more and more 
disqualified to support the body. Instead, therefore, of resorting to these 
contrivances in the beginning of lateral spinal curvature, the practitioner 
should devote his attention to the education, training, and development of the LATERAL CURVATURE. 
865 
faulty muscles, and, as much as possible, to diminishing the action of those 
which are concerned in producing the deformity. Numerous resources are 
at command to effect these objects, and the interest of the patient must be 
heartily enlisted in the matter, so that he may fully co-operate with the phy- 
sician. For example, a certain portion of the day should be devoted to carry- 
ing some light weight, as a book, a little bag of shot, or some other body, upon 
the top of the head, while the patient walks to and fro; the attention that is 
necessary to poise the body aids'in straightening the column by stimulating, 
through the will, the defective muscles. Another part of the day must be 
given to practicing those movements which chiefly affect the disabled muscles, 
as swinging by the arms, inclining the body in a direction opposite to the 
curve, or sitting on an inclined plane, which will necessitate the bending of 
the body in the same direction in order to resist the tendency to slide down. 
Another and a powerful measure is the plan introduced by Dr. Lee, of Phil- 
adelphia, of suspending the patient, after the manner described under the 
head of treatment in Pott's disease. The effect of this plan is to straighten 
at once the spine, and it should constitute a part of the drill for at least five 
or ten minutes every day. The patient can manage this part of the treat- 
ment alone, and need not raise the body higher than to allow the tips of the 
toes to touch the floor. One hour on the back in bed should always follow 
the extension. In addition to these means, the faulty muscles should be 
kneaded, pinched, and beaten, so as to invite a large supply of blood and 
improve the nutrition. An excellent muscle-beater is one which consists of 
a hollow gum ball attached to a flexible rod. 
Electricity, in the hands of one familiar with the nerve-points most directly 
related to the muscles involved, also constitutes an excellent stimulus. 
The function of respiration may likewise be utilized in helping forward the 
work of correcting or arresting these deformities, to obtain the full benefit 
of w'hich it is necessary to have an apparatus-that of Briggs or of Davis 
being the best-which consists of metal or leather pads, which are placed 
one under the axilla on the concave side of the curve, a second over the most 
prominent portion of the convexity, and a third and fourth over the opposite 
hips. These several pads are connected with one another by bands con- 
Fig. 1528. 
Fig. 1527. 
sisting partly of elastic material, and made fast by buckles. (Figs. 1527 
and 1528.) The transmission of power during inspiration through these 
Kolbe's apparatus for lateral curvature of the spine. 
Pavis's apparatus for lateral curvature. 
vol. ii.-55 866 
SURGICAL DISEASES OF THE SPINAL REGION. 
lines of communication between the pads, making pressure and counter- 
pressure at different portions of the thorax and pelvis simultaneously, favors 
the correction of the distortion not only by the movement of respiration, but 
also through the incitement to voluntary efforts in the same direction, arising 
from the ever-present consciousness of the pull of the apparatus. It should 
not be worn continuously longer than two or three days. 
When the curvature is due to an inequality in the length of the lower 
extremities, it can be best remedied by elevating the shortened member by 
an addition to the sole of the shoe, by a cork shoe, or by a patten. 
When the curvature is accompanied by muscular contractions, subcutaneous 
myotomy will remove an important obstacle in the way of correcting the 
deformity. Guerin, of France, at one time practiced this operation quite ex- 
tensively, but the empirical manner in which it was done tended rather to 
stigmatize than to commend the procedure. Sayre individualizes the faulty 
muscle by testing its reflex availability. This is done by raising the shoulders 
or bending the body in a direction opposite to the curve, when any muscle 
which starts out prominently, and, on being pinched, pressed, or tapped, 
contracts spasmodically, or excites spasms in other groups of muscles, is 
regarded as an offender, and immediately treated with the knife. 
By faithfully carrying out the above instructions many cases of the spinal 
distortion under consideration can in their incipiency be entirely corrected, 
many greatly improved, and almost all arrested. 
Cases, however, will come under notice in which the structural alterations 
have so far advanced that all attempts to correct the distortions must neces- 
sarily prove utterly useless. Such deformities demand mechanical appliances, 
with a view to prevent the continued increase of curves, and for this object 
the plaster, leather, or steel jacket (Fig. 1529) can be employed. 
Fig. 1529. 
Fig. 1530. 
Posterior curvature in an aged woman. 
Kolbe's spinal jacket. 
Posterior Curvature (Cyphosis). 
Posterior curvature of the spine, sometimes termed cyphosis, from the Greek 
word zuyog, "bent," is characterized by a marked convexity of the back, 
seated chiefly within the limits of the dorsal portion of the column, though 
the whole spine may participate in the distortion. The deformity is met 
with in both the young and the aged, and may be seen from the slightest 
forward inclination of the body to a degree in which the chin touches the 
knees. (Fig. 1530.) 
Infantile posterior curvature.-Often the deformity commences in infancy in 
consequence of general muscular weakness. The mother carelessly allows 
the child to sit on her knees or in its chair, and the head falls forward and POSTERIOR CURVATURE. 
867 
hangs like a weight at the long end of a lever, while the spine, plastic and 
non-resistant, from the presence of epiphyses and from the immature stage 
of ossification, gradually becomes more and more bent forward, at the same 
time developing the curve on the back. The muscular weakness in these in- 
stances of infantile posterior curvature depends upon constitutional causes, 
as rachitis, syphilis, tuberculosis, etc. 
Curvature of adolescence.-When the deformity arises in boys and girls, or 
in young adults, it is generally to be attributed to the influence of occupa- 
tion, certain trades and avocations conducing more than others to the cur- 
vature, as those of shoemakers, who habitually are obliged to lean over the 
lapstone and the last, of tailors, wrho sit and bend over their work, and of 
clerks and students, whose lives are sedentary, and who incline forward in 
their respective work or studies. 
Senile posterior curvature depends on diminished nutrition of the long 
muscles of the back, and the general impairment in the elastic structures of 
the spine, in consequence of which the old man leans upon the top of his staff, 
and his step becomes hurried, shuffling, and short, in order that he may keep 
up with his head, which is in advance of the rest of his body. 
The condition which is commonly termed "round-shouldered" is generally 
due to a degree of posterior curvature at the upper part of the dorsal spine. 
The pathological changes which belong to posterior spinal curvature are ab- 
sorption of the anterior portions of the intervertebral cartilages and bodies 
of the vertebrae, thus allowing the front portions of the latter to approximate 
one another. As this process continues, the supra- and interspinous ligaments 
yield, and the spinous processes become separated and correspondingly prom- 
inent. Nature sometimes interferes to prevent the continuance of the curve, 
especially in subjects who possess a rheumatic diathesis, by throwing out 
abutments of new bone, which reach across from the body of one vertebra 
to that of another. The deformity of the spine extends also to the thorax 
and to the lumbo-sacral articulation. The ribs project posteriorly, their con- 
tiguous bodies are brought close together, and the sternum is rendered un- 
usually prominent. The arms hang loosely in front of the body, their weight 
depressing the top of the shoulders, while in an equal degree it raises the 
inferior angles of the scapula. When the deformity includes the lumbar 
portion of the spine, the pelvis becomes bent towards the thorax, frequently 
to a degree which requires the person to walk with the legs flexed on the 
thighs and the latter flexed on the pelvis. 
Symptoms. - The signs of cyphosis are generally positive. The back 
exhibits a posterior curve which is formed at the expense of several verte- 
brae, and which is uniform and not abrupt, as in Pott's disease, the spinous 
processes are abnormally salient, the head and shoulders are bent forward or 
sunk down between the shoulders, and, when the person is required to direct 
the head to one side or the other, the movement is effected by the rotation 
of the atlas upon the axis, by which the side of the face is turned laterally 
and at the same time upward. In bad cases of this affection the crowded 
condition of the thoracic and abdominal viscera gives rise to functional dis- 
turbances of these organs, the muscles continue to waste, and walking 
becomes a labor. 
Treatment.-The treatment consists in removing, as far as possible, the 
exciting cause of the distortion, making extension of the spine, and applying, 
when necessary, a mechanical support. 
In fulfilling the first indication it will sometimes be necessary to address 
our therapeutics to the correction of some constitutional vice of the system, 
particularly in the case of young subjects, the remedies being some prepara- 
tion of iodine, iron, or cod-liver oil, with abundance of nourishment, particu- 
larly milk. 
No prolonged efforts at sitting up should be allowed, though, to a mod- 
erate extent, this posture will prove useful by inciting action in the long 
muscles of the back and contributing to their nutrition and strength. 868 
SURGICAL DISEASES OF THE SPINAL REGION. 
Another exciting cause in older subjects, and one correctible, is to be found 
in the occupation or calling of the patient, and when this is of a character 
to aggravate the deformity it must be abandoned or exchanged for another 
less harmful one. It is these cases of posterior curvature in young persons 
which are peculiarly tractable to the principle of extension by suspension, 
alternated with periodical rest upon the back, together with " massage." 
Mechanical support is only to be thought of in progressive cases, and in 
persons who, from necessity, are compelled to keep on their feet or to follow 
a predisposing calling; and then the best apparatus is the plaster jacket 
applied during suspension by the head, and, when the curve is lessened as 
much as possible, substituting for the plaster the leather jacket of Gemrig. 
(See Pott's disease.') 
Anterior Curvature. 
Anterior curvature, or lordosis, from the Greek word kopdoq, "bent for- 
ward," consists in an exaggerated curve of the spinal column, the convexity 
of which is directed anteriorly, and the concavity posteriorly. (Fig. 1531.) 
The curvature is generally confined to the lumbar 
and a few of the lower dorsal vertebrae, though no 
region of the spine is exempt. The deformity is either 
congenital, pathological, or acquired. 
The congenital origin of the curvature is seen in 
those peculiarities of organization which belong to 
some families, and which are transmitted from parent 
to offspring, among which may be specified bow-legs, 
short-legs, and sway-backs. Congenital dislocations 
of the femora also give rise to a similar incurvation of 
the loins. 
The pathological causes of the deformity are rickets, 
anchylosis of the coxo-femoral articulations, and dis- 
ease of the lumbar vertebrae. 
Acquired lordosis may be developed during gesta- 
tion, also from obesity, and from ovarian tumors. 
The curve in these cases being wholly compensatory, 
and necessary to maintain the centre of gravity, it 
spontaneously disappears on the removal of the 
cause. 
Pathological Changes.-When lordosis is the 
result of some cause of temporary duration, or one 
which is removable, as pregnancy, ovarian disease, 
or an unusual deposition of fat over the abdomen, it 
is not attended by any structural alterations of a 
serious nature; and the accommodation is secured 
chiefly through the normal flexibility of the spine. 
When, however, it is determined by conditions which 
are permanent, the vertebrae undergo changes the re- 
verse of those observed in anterior curvature or cypho- 
sis; that is to say, the pedicles are bent downward; the articulating processes, 
instead of being directed outward and backward, are changed so as to look 
backward and downward; the spinous processes are increasingly curved down- 
ward and flattened, in consequence of being crowded against one another; the 
anterior common vertebral ligament is elongated ; the bodies of the vertebrae 
are diminished posteriorly in their vertical diameters, while anteriorly they 
are separated, the interspaces being filled by the expansion of the inter- 
vertebral cartilages. 
Symptoms.-The symptoms of anterior curvature vary with the regions of 
the spine affected. As the pedicles yield, in bad cases of the disease, the 
nerves which pass through the intervertebral foramina are encroached upon, 
and then follows, if the depravity is limited to the lumbar region, a flabby 
Fig. 1531. 
Anterior curvature, or lordosis, 
of the spine. ANTERIOR CURVATURE. 
869 
state of the abdominal muscles, accompanied with flatulent distention of the 
intestines, and pain in the course of the spinal muscles. 
When the lumbo-dorsal portion of the column is the seat of the distortion, 
there exists posteriorly a deep concavity corresponding to this part of the 
spine; the abdomen becomes very prominent, the upper part of the trunk is 
thrown back, and the head is carried somewhat forward. This posture 
necessarily produces a change in the lumbo-sacral angle, causing a depression 
of the pubes and ilii, and an elevation of the iscbii and sacrum, giving to the 
hips an unusual prominence. The influence of these changes on the loco- 
motion of the individual is very characteristic. The lower limbs are not 
advanced in a steady, direct manner, but, considerably separated, are hitched 
forward with a sudden jerking movement, during which the body at the same 
time rocks from side to side. 
When lordosis affects the dorsal region, it is probably secondary to caries 
of some part of the spine above or below the curve,-that is, in the cervical 
or the dorso-lumbar region,-and is a compensation for the irregular curva- 
ture. The effect of the simultaneous presence of the two affections is to impart 
greater saliency to the angular prominence, and to cause an increased con- 
cavity posteriorly above and below the latter. 
Rotatory lateral curvature of the spine is sometimes seen associated with 
dorsal lordosis, the latter condition usually preceding the former. 
When the curvature is dorsal, pleurodynia and oppression of breathing 
may follow, or, if it is seated in the cervical region, there may be disturbances 
both of the organs of circulation and of respiration, with numbness and 
neuralgic pains in the arms. 
When the anterior curvature affects the cervical division of the spine, it is 
the sequel to caries of the same region at a lower point. The head is thrown 
back, and, the face being turned upward, the anterior portion of the neck is 
lengthened, the larynx prominent, and, in the event of reparation taking 
place in the diseased vertebrae, the malposition of the head may remain per- 
manent. 
Treatment.-Lordosis in a considerable proportion of cases requires no 
surgical interference. In those cases which arise from conditions that are of 
temporary duration, the curvature will disappear spontaneously on the re- 
moval of the excitant; and in those which are due to hereditary or patho- 
logical causation, the deformity is a necessity, or an adjustment of the skel- 
eton to extraordinary or unusual conditions, salutary rather than harmful, 
and, therefore, equally without the pale of mechanical and of medicinal thera- 
peutics. 
An exception to this general statement can be properly made when the 
lordosis exists along with caries of the vertebrae, in whatever region it may 
occur. Here artificial support becomes necessary; but the appliances used 
for that purpose need not differ from those ordinarily employed in the man- 
agement of caries or Pott's disease of the spine, described in detail under the 
head of the latter affection. 
Constitutional treatment is not to be discarded when the indications for 
its employment are present, in which event the appropriate remedies will not 
differ from those suited to a case of lateral curvature. 
Posterior angular curvature is the result of inflammatory destruction of 
a number of vertebra, together with their intervertebral cartilages. 
It is an exceedingly common disease, often followed by lamentable deform- 
ity. As with coxalgia, it is too frequently the case that the disease is allowed 
to make considerable progress before the suspicions of the medical attendant 
are awakened or his attention is directed to the spinal column. To Percival 
Pott the profession is indebted for a correct exposition of the pathology and 
treatment of the disease. 
Posterior Angular Curvature.-Pott's Disease. 870 
SURGICAL DISEASES OF THE SPINAL REGION. 
Posterior angular curvature occurs with nearly equal frequency in both 
sexes. No time of life, from the intra-uterine to old age, is exempt from the 
ravages of the disease, though the period between two and a half and ten 
years of age, when the developmental forces are most active in the spine, 
embraces by far the largest number of cases. It affects both the rich and the 
poor, though in our great cities the latter class suffer oftener from the disease 
than the former. I do not believe it is more commonly met with among the 
inhabitants of cities than among those of the country. 
While any region of the spine may be the seat of the disease, its very 
common location in the dorsal section of the column is a matter of general 
observation, but which has not as yet been definitely explained. The ques- 
tion as to the cause of the localization of the disease may with equal per- 
tinence be asked in regard to coxalgia and knee-joint disease. We naturally 
look for a solution of the problem from anatomical and physiological con- 
siderations, or such as grow out of structure and function. The dorsal por- 
tion of the spine is unquestionably, from its length and mobility, more 
vulnerable to traumatic agencies than either the cervical or the lumbar, and 
this fact may be sufficient to explain the election of this part of the column 
by the disease. In rare instances a single vertebra is affected, though com- 
monly two or three are finally involved. Occasionally separate regions of 
the spine are simultaneously attacked. 
Causes.-The disease may begin either in the intervertebral fibro-cartilages 
or in the bodies of the vertebrae, much in the same manner as inflammatory 
affections of the joints may commence primarily in the articulating cartilage 
or in the ends of the contiguous bones. The relative frequency with which 
the cartilages or the bodies of the vertebrae take precedence in the attack is 
not positively known, as the opportunities for making examinations in the 
incipient stage of the disease are rare. I am disposed to believe that in a 
large majority of cases the vertebrae are first affected, and that the cartilages 
subsequently disintegrate from the destructive effects of the contiguous 
inflammation. 
The bodies of the vertebrae consist almost wholly of cancellated tissue in- 
cluded in a thin film of compact bone covered by periosteum and in front by 
fibres of the anterior common vertebral ligament. Each piece is remarkably 
independent of its neighbor, having its own arterial and venous system; con- 
sequently the vascular communication which exists between the different 
vertebrae is in the main through the periosteum. 
Two classes of causes are accredited with producing the disease,-con- 
stitutional and traumatic. Those who refer it to the former believe that 
the prime factor in the morbid process is a strumous or tubercular state 
of the general system, and that the spinal disease is only a local manifes- 
tation of such a vice. Other surgeons, who espouse the traumatic theory, 
believe that the inflammation which affects the vertebrae is in no way pecu- 
liar, and is due to twists, strains, blows, concussions, etc., of the vertebral 
column. 
There are certain forcible objections to be urged against the traumatic 
theory. How are we to explain those cases of posterior angular curvature 
which appear long before the child is exposed to any external violence what- 
ever, and when, from its tender age and the constant watchfulness inspired 
by maternal affection, it is altogether improbable that any accident of the 
kind could have occurred ? Again, why does it happen that the subjects 
of this disease, as a class, are not at all remarkable for that irrepressible 
activity and daring which expose young boys and girls to accidents and in- 
juries? On the contrary, according to my observation, the children who 
suffer from Pott's disease are given to a more quiet, retiring, and thoughtful 
mode of passing time. Again, if traumatism is a sufficient explanation for 
Pott's disease, how are we to account for the fact that boys and girls suffer 
with about equal frequency, when it is well known that the former, from 
the nature of their amusements, are much more exposed to casualties than POSTERIOR ANGULAR CURVATURE. 
871 
the latter? And, finally, does not the history of cases of posterior angular 
curvature almost uniformly reveal an antecedent tubercular or strumous 
ancestry ? At least such has been the result of my inquiries; and I am, there- 
fore, not disposed to adopt the views entertained by some modern writers, 
until the knife and the glass of the pathologist furnish me something more 
satisfactory than speculation. As far as I am capable of judging, the disease 
commences by an infiltration or a disseminated formation of strumous or of 
tubercular matter in the cancellated tissue of one or more vertebrae. It 
does not follow that, coincident with such deposition, the active signs of the 
disease must appear; on the contrary, the formation may remain quiescent 
for many months, just as a cheesy lymphatic gland of the neck or a little 
mass of tuberculous granulations in the lung may repose quietly for a con- 
siderable period before softening or the work of destruction begins. A time, 
however, does arrive when some depreciation in the health, or some injury 
(and here is where traumatism comes in), kindles into activity the inflam- 
matory processes or osteitis, as the match when applied to the fuse explodes 
the charge of powder, which until then had lain quiet, giving no evidence 
of its tremendous capacity for evil. It is probable that in most cases of 
Pott's disease there is both a specific and a common inflammation at work, 
the former beginning in a tuberculous vertebra and losing its specific char- 
acter as it extends to the bodies of adjoining vertebrae which may have been 
entirely free from the original disease. 
Structural alterations.-As the cartilages disintegrate and disappear, and 
the bodies of the diseased vertebrae are destroyed by the inflammation in the 
periosteum, the superincumbent weight of the body, conjoined with muscular 
action, crumbles down the disorganized osseous tissue, while the bodies of 
those vertebrae above and below the diseased ones approach each other. As 
the arches and the articular spinous processes are not implicated in the 
devastation, the column still retains its lateral and posterior abutments, and 
as the centre of gravity, by the change in the bodies of the diseased verte- 
brae, falls somewhat in advance of the normal line, the spine yields, pushing 
out a posterior projection, the size of which will depend on the number of 
vertebrae destroyed. With the formation of this posterior angular curvature 
there occurs an unusual pressure in front, formed by the sternum and the 
Fig. 1532. 
Vertebrae excavated by caries 
ribs, the latter being crowded closely together at the vertebral extremities 
when the disease is situated in the dorsal part of the column. 872 
SURGICAL DISEASES OF THE SPINAL REGION. 
As the diseased vertebrae crumble away under the destructive osteitis and 
the adjoining ones fall together, the nerves are liable to suffer compression, 
although it is one of the marvels of this disease that seldom is any very 
serious injury sustained by the cord or its meninges or nerves, even though 
the disorganization may extend to several vertebras and the resulting deform- 
ity be very great. 
Sometimes the disease appears to be limited to the epiphyses of the bones 
and the intervening fibro-cartilages, without invading the bodies of the verte- 
brae, while at other times the cancelli of the bones present a gnawed, irreg- 
ular, excavated appearance, the exterior shell of compact tissue still remain- 
ing. (Fig. 1532.) 
As regards the amount of suppuration, there is nothing uniform. The 
pus may be small in amount, undergo a retrograde metamorphosis, and be 
removed by the absorbents, or it may undergo a cheesy, cretaceous trans- 
formation, and remain indefinitely in the midst of the ruin of the dis- 
organized vertebrae, or in contact with the reparative material, in which 
state it may prove a source of future mischief by provoking secondary 
abscesses. In other instances the suppuration may be profuse, forming 
collections between the bones and the thickened periosteum. 
Spinal Abscesses.-The direction and termination of spinal abscesses will 
be determined by the region of the spine affected. When the caries is located 
in the lumbar portion of the spine the pus may enter the sheath of the psoas 
magnus muscle, and finally reach the thigh, passing into the latter beneath 
Poupart's ligament and external to the femoral blood-vessels, forming a 
"psoas abscess" (Fig. 1533); or it may find its way between the fascia of the 
quadratus lumborum and abdominal muscles, and 
open on the outer border of the erector spinae mus- 
cle, constituting lumbar abscess, or may appeal' more 
anteriorly above Poupart's ligament, or, again, it may 
burrow beneath the internal iliac muscles, and pass 
over the brim of the pelvis, through the great sacro- 
ischiatic foramen, and appear in the gluteal region as 
a gluteal abscess. 
When the dorsal region is the seat of the disease, 
purulent collections frequently form between the 
bones and their thickened periosteum, or the pus 
may work its way posteriorly and appear on the 
back a short distance from the spine. 
In caries of the cervical vertebras, spinal abscess 
may open into the pharynx, or, if the resistance of 
tissue compels the pus to find its way externally, it 
will be likely to do so between the longus colli and 
scaleni muscles, and appear on the side of the neck 
behind the sterno-cleido-mastoid muscle. 
Symptoms.-It is a matter of great consequence to 
discover the disease at the earliest possible period. 
If it is recognized only when the deformity ap- 
pears on the back, much valuable time has been 
lost, the proper use of which would have been of vital importance to the 
patient. 
Long before there is any external manifestation of the disease there exist 
a number of subjective signs which are quickly detected by a sagacious phy- 
sician. These signs differ according to the location of the disease; the earliest 
are those which result from the irritation of certain spinal nerves where 
they leave the intervertebral foramina, the effect of which is transmitted 
to their peripheral branches. 
When disease begins in the lumbar region, the patient often complains of 
colicky pains in the abdomen having a flatulent origin, and not unfrequently 
Fig. 1533. 
Psoas abscess. POSTERIOR ANGULAR CURVATURE. 
873 
is found to assume some unusual position when in bed, sometimes on his breast, 
sometimes on the hands and knees. Irritation of the bladder, attended with 
frequent urination, and sometimes incontinence of urine, together with darting 
pains above the thighs, are also among the early phenomena which betray 
the disease when seated in the lower part of the spine. When the dorsal 
region of the column is invaded, in addition to the symptoms of gastric irri- 
tation there are intercostal pains, a feeling frequently of constriction about 
the body, and possibly some little discomfort about the chest. The respira- 
tion is often carried on in a short, grunting manner, the power of the respi- 
ratory muscles being diverted, if the expression may be allowed, from the 
movement of the chest to aid in fixing the spine. 
Should the cervical region suffer, there may be difficulty of deglutition, 
choreic movements of the muscles of the neck, tingling and numbness of the 
arms, or an irritating laryngeal cough. 
In whatever part of the spine the disease is situated, the behavior of the 
child will be changed. If, in moments of play, the little patient should jump 
from a chair or sofa upon the floor, the concussion communicated to the spine 
produces a momentary confusion of thought; he staggers, looks surprised, 
and possibly falls. He is soon tired at his play, and is disposed to lie down 
or to lean over the nearest object for support, with one limb crossed over 
its fellow. As the disease progresses, the movements of the patient become 
restricted and artificial; every muscle is engaged in immobilizing the spine 
and relieving it from the superincumbent pressure. If the child sits, the 
hands are placed on the thighs, in order to take off the weight of the shoul- 
ders from the column. In standing, the head is thrown back, the shoulders 
are raised by the trapezii muscles, the arms allowed to hang by the sides, 
with the palms of the hands directed backward, and the feet turned out. 
(Fig. 1534.) In walking, the same posture is maintained, but the feet, instead 
Fig. 1534. 
Fig. 1535. 
of being raised and put down with confidence or indifference, are shuffled 
along with a studied care. At other times he will move only by reaching 
Standing position in Pott's disease. 
Manner of picking up an object in Pott's disease. 874 
SURGICAL DISEASES OF THE SPINAL REGION. 
with his hands from one article of furniture to another. When he wishes 
to pick up any object, instead of bending forward, as in health, the little 
patient will squat down by flexing the legs and the thighs, and reach for the 
object, while the body is kept rigidly straight (Fig. 1535), and he will rise in 
the same careful manner observed in stooping. 
The presence of such phenomena will at once suggest a careful investiga- 
tion of the spine. In conducting this part of the examination, the child must 
be divested of its clothing, and either made to stand with the trunk slightly 
bent forward, or be placed across the knees of the surgeon. Frequently 
an unusual prominence of one or more spinous processes will be detected 
as the earliest external manifestation of the commencing posterior angular 
curve, indicating that the destruction of the implicated vertebrae is in prog- 
ress. While in the positions already described, the spine may be further 
tested by extension and by pressure. If one hand is placed over the back 
and the other over the front of the head, and the child is partially raised 
from the floor, or if the limbs across which the child lies are separated, 
the elongation or stretching of the column thus produced will be followed 
by a sudden amelioration of all the symptoms; while if the vertebrae are 
crowded together by simultaneous pressure made at the extremities of the 
spine, there will be an aggravation of suffering, spasmodic movements of 
certain muscles, with probably a cry or some other sign of uneasiness ex- 
torted from the patient. Little is to be learned from tapping or percussing 
the spinous processes in order to develop tenderness or pain over the affected 
vertebrae: the vibrations do not reach the bodies of the bones, but are ex- 
pended on the arches and other processes. Lateral pressure applied to the 
ribs will sometimes develop pain when percussion over the spinous processes 
gives a negative result, because the ribs are directly articulated with the 
bodies of the vertebrae and the intervertebral cartilages. 
In well-marked cases of Pott's disease the angular curvature on the back 
is very prominent. (Fig. 1536.) When the disorganization and displacement 
are great, the spinal cord and nerves are exposed 
to pressure which sometimes is sufficient to inter- 
rupt the transmission of the nervous power, and, 
when the disease is in the lower dorsal and lumbar 
regions, will occasion paralysis of the lower ex- 
tremities, and of the bladder and rectum. 
Inflammation of the meninges of the cord is 
occasionally provoked by the irritation to which 
the membranes are exposed. The irresistible ten- 
dency to keep the feet in motion which is often 
seen in children suffering from the disease may 
generally be interpreted as an evidence of menin- 
geal irritation; and to the same cause may be 
ascribed many of those eccentric surface sen- 
sations which are experienced, as formication and 
localized hypersesthesia. 
As the local disease advances, the general system 
begins to suffer. The child loses flesh, the muscles 
waste, the face becomes pale and sickly, the appe- 
tite fails, all youthful vivacity disappears, and the 
child either becomes fretful and capricious in tem- 
per, or assumes a quiet, sober, pensive air far in 
advance of its years. 
Diagnosis.-Pott's disease may be mistaken for 
rheumatism, neuralgia, aneurism of the thoracic 
or of the abdominal aorta, chronic disease of 
the kidneys, abscess, superficial spinal caries, and emotional or hysterical 
disease. 
When the affection has advanced to the stage in which the spinous processes 
Fig.1536. 
Angular projection of the spine. POSTERIOR ANGULAR CURVATURE. 
875 
project posteriorly, forming the angular curvature, there can of course be 
no difficulty in recognizing the nature of the disease. The uncertainty or 
obscurity of diagnosis is limited to the initial stage. 
In investigating a case of supposed Pott's disease, we may generally dis- 
tinguish it from the above-named diseases and arrive at a correct conclusion 
by attending to the following considerations: 
Rheumatism.-Rheumatism of the spine in children is very uncommon, 
and when it does exist the attack is sudden, the pain or uneasiness is not 
limited to a very circumscribed area, but is diffused, does not materially 
affect the movements of the patient, and is not relieved by extension of the 
spine. Contrast this group of symptoms with those which characterize 
posterioi' angular curvature,-by no means an uncommon disease,-its slow 
approach, the localized pain, the general disability of the spine exhibited in 
almost every movement, and the immediate relief from all discomfort on 
stretching the column, and it is not probable that the error of confounding 
the two diseases will be committed. 
Neuralgia.-In intercostal neuralgia, independent of spinal caries, the pain 
is intermittent, while in spinal caries it is constant; again, if the vertebrae 
are crowded together the pain in neuralgia is not aggravated, but is so in 
actual disease of the spine. 
donsm.-Thoracic and abdominal aneurism are diseases of adult life, and 
may be excluded from the category of affections which complicate the diag- 
nosis of infantile disease of the spine, but must be entertained when we come 
to differentiate spinal disease in adults. 
The throb of the aorta, resting as it does against the spinal column, will, 
when it undergoes aneurismal dilatation, occasion absorption and caries of 
the vertebrae with which the tumor is in contact. The pain, too, is local, 
and, as the bones are wrorn, there may follow a slight projection in the dorsal 
region. There are, however, notable distinctions between the two diseases. 
Aneurism may be developed in persons whose antecedent history reveals no 
hereditary vice. Rarely is this the case with adult subjects of angular curva- 
ture. A careful inquiry will usually reveal the fact that one of the parents, 
or a brother or sister, has died of consumption or cancer, and that the indi- 
vidual himself, when young, had been the subject of glandular enlargements 
of the neck. As many members of the profession attach great importance 
to syphilis as a cause of aneurism, the state of the patient in this respect 
would legitimately enter into the inquiry. Again, the movements of the 
patients in the two affections are entirely dissimilar. There is never in an- 
eurism that fixed state of the entire spine which tells in the walk, as in every 
other motion, of persons with true Pott's disease. With these differential 
signs may be contrasted the infrequency of any angular curvature in aneu- 
rism and its constancy in primary spinal caries; and, lastly, the existence often 
of characteristic sounds in aneurism which are never present in angular 
curvature. 
Disease of the kidneys.-Chronic disease of the kidneys, which is often ac- 
companied with pain in the back, can generally be recognized by an exami- 
nation of the urine. 
Abscess.-The most difficult task is to distinguish those abscesses which 
sometimes form in the course of the spine, and which are in no way depend- 
ent on inflammatory disease of the vertebrae, from those w'hich accompany 
Pott's disease. We say that abscesses dependent on disease of the bodies of 
the spine generally point in the groin, either above or below Poupart's liga- 
ment, or in the lumbar region ; but, while this is true, there are others which 
appear in the same localities wholly unconnected with any bone disease what- 
ever, as those which originate in the cellular tissue about the kidney,-perine- 
phritic,-or around the head of the colon,-periccecal,-or in the iliac fossae, 
or in the lumbar glands, or even in the cavity of the thorax,-empyemic. If 
the abscess has a pcrincphritic origin, it will be likely to point in the lumbar 
region, and will be accompanied by signs of renal disturbance; if periccecal, 876 
SURGICAL DISEASES OF THE SPINAL REGION. 
the abscess will be limited to the right side, and will be attended with deep- 
seated iliac pain on pressure, and with intestinal symptoms. 
Iliac and psoas abscesses, when disconnected with bone disease, as a rule, 
arise from traumatic causes and develop with considerable rapidity. Indeed, 
in all abscesses situated within the abdomen and in the neighborhood of the 
spine, and not dependent on actual disease of the latter, the symptoms are 
more acute, the chills more pronounced, the fever partakes more of the con- 
tinued than of the hectic type, and the pus is more healthy than when asso- 
ciated with spinal disease; to which may be added the fact that they are 
unattended with any spinal deformity corresponding to posterior angular 
curvature. 
Empyema.-Tn those rare instances in which a purulent collection finds its 
way beneath the arcuate ligaments of the diaphragm and along the psoas 
muscle to the groin, there has been an antecedent history of pleuritis or 
pleuro-pneumonia. 
Superficial spinal caries.-There is a form of spinal caries altogether dis- 
tinct from Pott's disease, but which is liable to be confounded with the latter, 
in consequence of the location of the accompanying pain and the existence 
of abscess. This variety of caries is occasioned by cold or by sprain, and 
sometimes by constitutional causes; it commences as a periostitis, affects 
two or three vertebrae at the same time, shows little tendency to penetrate 
deeply, and is not attended with angular curvature. The progress of the 
disease is slow, and its termination in the adult usually fatal, the patient 
dying from exhaustion. Young subjects may recover. 
Emotional imitations of spinal disease, or those which relate to the will, 
may be detected by attending to the following facts. There is no evidence 
that the functions of the cord are materially interfered with, inasmuch as 
the nutrition and the reflex actions remain undisturbed. The phenomena 
are to be referred to the brain rather than to the medulla spinalis. They 
appear and disappear suddenly, and often under some mental excitement; 
the subjects are persons who exhibit othei' evidences of being emotional, 
and who are of an age at which the ideal dominates the real; and, finally, 
these mimicries are strengthened by the very notice which they attract. 
Prognosis.-Posterior angular curvature is always to be regarded as a 
serious disease. There are two things to be considered in the prognosis, 
namely, the amount of deformity, and the life of the patient. 
With reference to the deformity, much will depend on the constitutional 
condition of the subject, the early recognition of the disease, and the char- 
acter of the treatment; but, even when all these are in favor of the patient, 
less or more deformity will exist, and this never can be corrected. 
Life, however, is not seriously imperiled by the disease. Many persons 
with curved spines are seen in every sphere of life, well advanced in years, 
and capable of laborious occupation. Few children who receive proper care 
perish from angular curvature. Of those whose cases I have been able to 
follow I recall only two who have died from causes directly traceable to the 
spinal affection. In one of these the mother, in opposition to strict instruc- 
tions to the contrary, allowed the child on several occasions to walk across 
the room without the accustomed support. This he did with great difficulty, 
and in one of these attempts the little fellow suddenly doubled up, fell on the 
floor, became paraplegic, and died in a convulsion. In forming a prognosis 
the locality of the disease must be considered, the most favorable cases being 
those in which the affection is situated in the lumbar or dorsal region. When 
the disease attacks the cervical portion of the spine, the danger to life is 
greatly increased. This arises sometimes in consequence of the formation 
of abscesses which open into the pharynx or into the spinal canal and com- 
press the cord. Life is also in danger of being suddenly destroyed by dis- 
placements of the vertebras, due either to destruction of their bodies or to 
rupture of the transverse ligament. 
Nothing renders the prognosis more unfavorable than the existence of POSTERIOR ANGULAR CURVATURE. 
877 
abscess. Many cases of this form of spine disease pass through every stage 
without any external evidences of abscess; and it is not an overstatement 
to say that more children perish from abscesses which open internally than 
from all other causes combined. Under any circumstances, recovery from 
Pott's disease is a slow process, requiring in most instances from three to ten 
years for its completion. 
Repair.-The repair of the damaged portion of the spine is by anchylosis, 
and this may commence in one part while the disease is in progress in another. 
There is a remarkable provision of nature witnessed in the plan or order of 
this repair. While the destructive process is going on in the bodies of the 
vertebrae, there occur an inflammatory thickening and agglutination of the 
soft tissues around the seat of disease, in order, it would seem, to erect a bar- 
rier which shall separate the diseased from the adjacent sound tissues. The 
periosteum covering the arches and processes participates in this general ac- 
tivity, and, in virtue of its osteogenetic property, unites all together by bridges 
and columns of bones. This consolidation of the posterior appendages of 
the affected vertebrae may lessen the angular curvature by preventing the 
bodies of those vertebrae which arc outside of the limits of disease from ap- 
proaching each other, though it will certainly render the patient less secure 
than when, in addition to the osseous union of the arches and processes, the 
chasm or gap between the bodies is diminished sufficiently to be also spanned 
by bridges of bone. 
Considerable angular curvature, therefore, while it greatly mars the beauty 
of the form, compensates for the deformity by making the consolidation of the 
column more secure. In all these reparative processes the cord is not en- 
croached upon, and the intervertebral foramina for the passage of the spinal 
nerves are preserved. 
Treatment.-In the treatment of Pott's disease both general and local 
measures are to be employed. The former include the use of all those 
remedies which tend to improve the blood and strengthen the constitution, 
and which co-operate with natural processes in eliminating the diathesis 
on which the disease depends. For these ends cod-liver oil, the iodide of 
iron, and the phosphates, together with a nutritious food and fresh country 
air, are the most important. The local treatment is even more valuable 
than the constitutional, as without this the former can accomplish little 
good. 
If the disease develops before the child is able to walk, rest in the recum- 
bent position is imperative. The little patient can be laid upon a pillow or 
on a sacking-bed, which, sinking somewhat in the middle, will prevent the 
child from turning upon the side. When the circumstances of the parents 
will permit, an air-bed is to be preferred. During pleasant days the bed can 
be placed upon wheels and pulled into the open air. By maintaining the 
horizontal position the spine is relieved of the weight of the body and the 
traction of the muscles, and by its being preserved in a fixed state of rest 
several very potential excitants to inflammation are avoided. How long this 
enforced rest is to be kept up must be determined by the locality of the dis- 
ease. When the disease is seated in the cervical or eervico-dorsal region, the 
only period I would fix would be that at which anchylosis was established 
and the child well, as no apparatus ever devised by the ingenuity of man 
can sufficiently relieve the spine from the weight of the head to render 
the erect position safe. When the disease makes its appearance in a child 
who has for some time been moving about, whether seated in the lumbar 
or in the dorsal region, it would be well if the horizontal position could 
be enforced for at least six or eight months. This, however, is not always 
feasible. 
There are circumstances inseparable from social life which make it neces- 
sary that the patient should be as little dependent as possible, and it is some- 
times necessary, in order to rescue him from the designs of irregular char- 
latans, that he should be placed on his feet at the earliest possible moment. 878 
SURGICAL DISEASES OF THE SPINAL REGION. 
When the disease, therefore, is seated in the lumbar vertebrae, or not above 
the fifth dorsal vertebra, a mechanical appliance can be adjusted which will 
afford an excellent support to the spine, and by wearing which the cure may 
progress without any very serious drawback. Most of the appliances which 
have been in use for this purpose propose to relieve the spine of the super- 
incumbent weight by crutches placed under the arms and fastened below to 
a padded band of metal, thus distributing the weight of the shoulder over the 
hip and the sacrum. This form of apparatus is secured to the person by a 
laced corset, or by buckles and straps (See Fig. 1529.) That such a mech- 
anism imparts some security to the spine is doubtless true, but that it is far 
from meeting the true necessities of the case must be apparent to any one 
at all familiar with spinal physics. When the disease is seated high up in 
the dorsal region a head-support is necessary, and one can be attached to the 
jacket (Fig. 1537), which is susceptible of being raised or lowered at pleasure, 
and which lessens the weight to be 
borne by the spine, as from this sup- 
port the head is suspended by chin 
and occipital bands. (Fig. 1538.) 
To Professor Sayre, of New York, 
the profession is indebted for the 
most important dressing in the treat- 
ment of this form of spinal disease, 
and for the discovery of which hu- 
manity owes him a debt of everlast- 
ing gratitude. It is valuable alike 
for its efficiency and its simplicity. 
The plaster dressing to which I 
refer is applied in the following 
manner. The child is divested of 
its clothing and fitted with a knit 
woolen shirt extending a short dis- 
tance below the hips and without 
sleeves, in lieu of which two straps 
of the same material are pinned or 
tied over the shoulders. This shirt 
must adapt itself so accurately to the figure of the patient that there shall 
be no creases. The child is now placed under a tripod, or a beam, to which 
are attached a compound pulley and a leather head-gear. (Fig. 1539.) The 
pulley being lowered and the apparatus designed to embrace the occiput and 
the chin adjusted, the child is raised by drawing upon the cord until the toes 
barely touch the floor. (Fig. 1540.) 
The extension is made directly on the spine, and, while this is kept up, 
the surgeon takes a plaster roller two and a half inches wide and from five 
to seven yards long, and, soaking it for two minutes in a basin of water and 
then squeezing the redundant fluid well through its pores, makes one or 
two turns round the pelvis, between the trochanters and the crests of the 
ilii, continuing its application regularly up to the axilla?, each turn over- 
lapping the preceding about one-third. Three or four additional rollers are 
applied in the same way, observing to smooth the plaster by passing the 
dry hand frequently over the surface of the roller. 
In ten minutes the plaster will have become sufficiently hard to admit of 
the child being taken under the arms and, after the head-gear is unbuckled, 
laid at full length upon a hard mattress, in which position he should remain 
for from three-quarters of an hour to an hour, after which the clothing may 
be put on and he may be allowed to go about. 
By this plan the body is encased in a hard shell or coat of mail which fits 
into every inequality of the surface and thus distributes the support over an 
extended superficies. If desired, the plaster can now be sawed or slit up in 
front with cutting pliers, and its edges bound with leather having holes and 
Fig.1538. 
Fig. 1537. 
Spinal jacket with head- 
support. 
Suspension apparatus 
applied. POSTERIOR ANGULAR CURVATURE. 
879 
studs so as to be laced up in front. The support for the arms can be made 
comfortable either by introducing crutches between the layers of the bandage 
or by turning over the upper turns of the bandage so as to give the sub- 
Fig 1540. 
Fig. 1539. 
Suspension apparatus. 
Child suspended. 
axillary portion of the dressing a rounded form. This must be done before 
the plaster hardens. 
As it is of great importance that the weight of the head should also be 
taken off the spine, a head-support should be in readiness to make fast to the 
plaster appareil. This is formed of two parts, a back-piece and a head-piece, 
the first consisting of a plate of steel containing a socket with a button- 
headed screw, and two pieces of strap-iron perforated with holes; the second, 
a rod of steel fashioned at its lower end so as to drop into the socket, and 
bent so as to conform to the back of the neck and the head, above which it 
must extend, and having fastened to its extremity a swivel and head-gear. 
(Fig. 1541.) The back-piece of this suspension apparatus is secured between 
the layers of the plaster bandage, being applied between the first two and the 
last rollers. The head part is adjusted subsequently while the patient is 
standing, by introducing its rounded extremity into the socket, arranging 
the head-gear under the chin and the occiput, and then raising it until the 
proper degree of support is obtained, when, by turning the button-headed 
screw, the support is fixed in position. 880 
SURGICAL DISEASES OF THE SPINAL REGION. 
Mr. Gemrig, one of the prominent surgical cutlers of Philadelphia, has 
constructed from half-tanned leather a spinal jacket which I find to answer 
the purpose of support quite as well as plaster, and which is very much 
lighter and far more dura- 
ble. In forming this leather 
jacket the child is clad in 
a knit shirt and suspended 
from the tripod and sur- 
rounded by the plaster roll- 
ers, precisely as in the appli- 
cation of the dressing already 
described. As soon as the 
plaster has hardened, and 
before the patient is low- 
ered, the bandage is slit up 
in the centre and removed. 
(Fig. 1542.) From this shell 
is taken a plaster cast, over 
which the leather is accu- 
rately moulded. 
One thin strip of steel is 
riveted to the leather on 
each side in a line running 
between the armpit and the 
hip, in order to prevent any 
tendency in the jacket to 
break down, and a thin piece 
is fastened to the back, which 
contains the socket for the 
head-suspension. (Fig. 1543.) 
The apparatus is perforated 
in order to render it as light 
as possible, and is secured to 
the body by a lacer passed 
around a row of studs ar- 
ranged along each side of the 
opening in front of the jacket. 
(Fig. 1544.) 
Mr. Johnson, of Philadel- 
phia, has constructed a spinal 
jacket of felt, a mould being 
first procured by taking a 
plaster cast of the trunk. 
(Fig. 1545.) In two instances 
where I tried the felt appa- 
ratus, however, it failed to 
answer the purpose. 
When anchylosis has taken place and the column has become consolidated 
about the seat of the disease, which may be known by a permanent arrest 
of the angular excavation and by the firmness of the anchylosed parts, the 
jacket should be gradually withdrawn, at first for half an hour every day, 
lengthening the period by degrees, until it can, in the course of four or five 
months, be dispensed with entirely. The muscles of the back in the mean 
time should be treated by " massage," in order to improve their nutrition 
and strength. 
The various local applications which have been employed at different times, 
as setons, issues, the cautery, blisters, iodine, and various irritants, are many 
of them positively injurious, and from the use of even the mildest of these 
agents I have never seen any positive benefit result. 
Fig. 1542. 
Fig. 1541. 
Apparatus for supporting the 
head. 
Piaster applied and slit up in order 
to prepare plaster cast. POSTERIOR ANGULAR CURVATURE. 
881 
Complications.-Among the complications which attend posterior angular 
curvature of the spine are abscess and hip-joint disease, or coxalgia. 
Spinal abscess is more to be 
dreaded than any other com- 
plication of angular curvature, 
except, perhaps, destructive le- 
sion of the cord. I have already 
stated that it is the principal 
cause of death in Pott's disease. 
Abscesseswhich open posteriorly 
in the dorsal region-much the 
less common form-are not so 
serious in their consequences as 
those which follow the bodies 
of the vertebrae and become 
finally visible at a point remote 
from their origin, because the 
place where they point is near 
the seat of disease, and they 
do not, consequently, attain the 
same magnitude or cause the 
same destruction of tissue as 
the latter. 
All of these abscesses, except 
those originating in the cervical 
part of the column, naturally 
seek an outlet in the direction 
of the inguinal, iliac, lumbar, or 
gluteal region. 
There are two reasons for 
this,-a physical and an ana- 
tomical one,-viz., the 
influence of gravity, and 
the peculiarities of struc- 
ture. 
Cervical abscess.-When 
the caries involves the 
vertebrae of the neck, ter- 
minating in suppuration, 
the abscess will proceed 
in one of two directions, 
either anteriorly, the tu- 
mor presenting behind 
the posterior wall of the 
pharynx, or postero- 
laterally, the pus dissect- 
ing its way between 
the longus colli and 
the scaleni muscles, and 
reaching the external 
surface of the neck pos- 
terior to the stern o- 
cleido - mastoid muscle, 
turning the head to the 
opposite side. 
There is a retro-pha- 
ryngeal abscess which 
commences in the cellular tissue between the pharynx and the periosteum 
of the cervical vertebrae which might be confounded with spinal abscess 
Fig. 1544. 
Fig. 1543. 
Leather spinal jacket with 
head-piece. 
Leather apparatus applied. 
Fig. 1545. 
Johnson's felt jacket applied. 
vol. ii.-56 882 
SURGICAL DISEASES OF THE SPINAL REGION. 
taking the first direction; but, as the latter is always associated with well- 
marked symptoms of previous disease of the vertebras, it is not probable 
that any diagnostic error would be committed. 
Pulmonary spinal abscess.-If the abscess begins in the dorsal region, the 
pus, as it accumulates, presses the periosteum away from the bodies of the 
vertebrae, carrying with it the reflected layer of the pleura. It has happened 
at this stage of the disease that, through inflammatory adhesion, the two 
layers of the pleura, with the lung, have become united to the periosteum 
or sac of the abscess, and through ulceration the purulent accumulation has 
opened into one of the bronchial tubes and been discharged by the mouth. 
Psoas abscess.-When the abscess which has been described above as com- 
mencing in the dorsal region continues to displace the periosteum and the 
pleura in the downward direction, it is for a time arrested at the lower part 
of the chest, where the diaphragm arches over the lumbar muscles, and is 
there detained until a passage is formed beneath the internal arcuate liga- 
ment, when it enters the substance of the psoas magnus, being covered by the 
sheath of that muscle, and lying behind the reflected peritoneum. As the 
pus descends, it finally reaches Poupart's ligament, and, passing beneath the 
latter, appears in front of the thigh, forming a fluctuating swelling on the 
outer side of the femoral vessels, constituting what is commonly called psoas 
abscess. (See Fig. 1533.) 
The abscess may take the same course when the disease which creates it 
is situated in the lumbar vertebrae. When the origin of a psoas abscess is 
in the dorsal region, and its termination is in the groin in front of the thigh, 
the sac assumes the form of a large cylinder with two constrictions, corre- 
sponding the one to the arcuate ligament of the diaphragm, and the other to 
Poupart's ligament. These abscesses sometimes contain an enormous amount 
of unhealthy pus. 
Psoas abscess has been confounded with femoral hernia; but there is a 
single test which will serve to establish the distinction, and that is the rela- 
tion to the femoral blood-vessels,-psoas abscess being always on their outer 
side, and femoral hernia on their inner side. 
Iliac abscess.-In the case of an abscess which has passed the diaphragm, 
or in one which commences in the lumbar region, should the pus in its 
descent follow the outei- surface of the psoas muscle, it may enter the iliac 
fossa, and, should it not subsequently find its way into the psoas compart- 
ment of the iliac fascia, will form a rotund tumor in the iliac region, limited 
by the crest of the ilium. An abscess thus situated is called an iliac abscess; 
the abdominal parietes may become united to its anterior surface, wThen the 
opening will probably occur somewhere in the neighborhood of the anterior 
superior spinous process of the ilium. In the case of a young lady suffering 
from caries of the lumbar vertebrae, whom I attended in connection with 
Dr. Allen, of this city, an abscess of this nature following the course of the 
fascia transversalis found its way to the surface, apparently through the 
inguinal canal. 
Lumbar abscess.-Again, a spinal abscess which begins in the dorsal and 
enters the abdominal region, underneath the external arcuate ligament, will 
most probably pass into the structure of the quadratus lumborum, and, in 
consequence of the absence of the ribs, meeting with little resistance in the 
posterior direction, will at length point ovei' the loins, forming a lumbar 
abscess. Even when the origin of the abscess is lumbar it may take the same 
course, the pus passing beneath the little tendinous arches which separate the 
origins of the psoas magnus muscle from the lumbar arteries and entering 
the quadratus lumborum muscle, through which it passes to the back. 
The effect of these purulent collections is to destroy the muscles in which 
they burrow, and, as they grow in magnitude, to increase the inflammatory 
thickening of the sac, until, as in the case of the iliac and the psoas abscess, 
it not unfrequently becomes a dense, strong membrane. 
Gluteal and femoral abscess.-A spinal abscess may, after entering the iliac POSTERIOR ANGULAR CURVATURE. 
883 
fossa, or when under the deep part of the psoas muscle, take one of three 
directions : 
1st. Inward to the brim of the pelvis, passing between the pelvic fascia and 
the pyriform muscle, and entering the gluteal region through the great sacro- 
sciatie opening. 
2d. After forming an opening through the attachment of the iliac fascia to 
the crest of the ilium, the pus may reach the gluteal region by a more direct 
route. In the latter case, however, the gluteal abscess is over and between 
the gluteal muscles, while in the former it is beneath and below. 
3d. The pus may, after passing beneath the pelvic fascia, reach the inner 
part of the thigh through the thyroid foramen. 
In addition to these different modes of pus extension, spinal abscess may open 
into the bladder or into the rectum or other portions of the intestinal canal. 
Treatment.-A spinal abscess pointing either in the pharynx or on the 
side of the neck should be opened early. The former, if left without inter- 
ference, might suddenly open during sleep and destroy the patient by suffo- 
cation ; the latter causes increasing disorganization of the structures of the 
neck, not exempting the great vessels of the region. The rule in opening 
a deep-seated abscess in the neck is, in place of making the usual puncture, 
to incise the skin, superficial fascia, and platysma muscle consecutively, and, 
upon reaching the deep fascia, to make in it a small opening, through which 
a director is to be carried, and any parts intervening between the fascia and 
the abscess broken up until the pus appears, when the orifice in the cervical 
fascia can be enlarged on a director. 
Abscesses which appear externally on the back over the dorsal region 
should be allowed to remain undisturbed as long as they show no decided 
tendency to increase. I have watched such for many months with the satis- 
faction of seeing them at length absorbed. If, on the contrary, the purulent 
collection continues to increase, it should be evacuated by aspiration, and the 
sides of the sac brought into contact by a compress held in place by an elas- 
tic bandage or by long strips of adhesive plaster. If the abscess reappears, 
it is useless to temporize with the aspirator: it should be opened with the 
bistoury, the contents evacuated, a small drainage-tube inserted, and the in- 
terior of the cavity daily treated by injections of a solution of permanganate 
of potash, followed by carbolized water, after which the parts should be 
covered with antiseptic gauze and a little pad of carbolized oakum. 
The management, however, of a psoas, iliac, lumbar, gluteal, or femoral 
abscess, in which the matter has traveled a long distance, which has caused 
extensive changes of structure, and which possesses within its walls an 
enormous expansion of blood-vessels, is a much more serious problem. The 
surgeon is placed in a dilemma either horn of which is bad. If the abscess 
is opened as soon as it becomes accessible, the abstraction of its contents is 
followed by severe constitutional irritation, and the patient is liable to sink 
from hectic exhaustion. If, on the other hand, the surgeon does not interfere 
until the swelling becomes so voluminous that the inflamed and attenuated 
skin threatens to give way and the abscess to open spontaneously, he is 
sensible that during all this time the evil is increasing by the continued ac- 
cumulation of pus and the consequent enlargement of the sac, together with 
the disturbance and disorganization of adjacent structures, and that, whether 
the abscess is opened by natural or by artificial means, the result is likely to 
be fatal. The danger in both cases is from two sources, namely, the purulent 
infection of the blood and the depletion of the blood-vessels in consequence 
of the profuse transudation of leucocytes from the vessels of the sac when 
the pressure from its interior is removed. If it were possible to recognize 
and locate the abscess early, with the certainty that the surrounding adhe- 
sions between its walls and the surface had formed before it had attained any 
considerable size, the propriety of its immediate opening would, in my judg- 
ment, scarcely admit of a doubt, as under these circumstances the sources 
of constitutional poisoning and depletion would be greatly limited, and the 884 
SURGICAL DISEASES OF THE SPINAL REGION. 
subsequent hectic correspondingly lessened in severity. Generally, how- 
ever, the surgeon does not meet with this happy combination of conditions: 
he must, of course, be prepared to treat the case as it commonly presents 
itself, and decide accordingly. Under these circumstances it is best to delay, 
interfering only when the sldn over the abscess begins to assume that purple 
hue which foreshadows the formation of a spontaneous opening. 
The result, as I have remarked, will be the same, but the patient will have 
gained several months of life. 
When the time arrives for opening the abscess, the operation may be done 
either with the aspirator or with the bistoury. If the latter is used, it would 
be advisable that the puncture, which should be somewhat indirect (see Cold 
Abscess'), be made under the antiseptic spray. To what extent the contents 
of the abscess are to be removed will depend on the constitutional effect pro- 
duced. If the patient grows weak and faint before the whole amount is evac- 
uated, it will be better to suspend the tapping and repeat it at a future time. 
Unless such a necessity arises, I prefer, however, after removing the pus, 
to introduce at once a drainage-tube and dress antiseptically. The constant 
withdrawal of the purulent contents by this plan favors the gradual collapse 
of the walls of the sac and diminishes its vascularity. It is true that in 
many instances the walls of the abscess are ad- 
herent to surrounding parts which will not yield, 
and this collapse is thereby prevented ; but this 
condition may affect only a portion of the sac, 
and therefore the treatment will not be useless. 
When feasible, as in iliac and lumbar abscess, 
pressure may be superadded, which will conduce 
to the same end,-that of diminishing the puru- 
lent cavity. 
Traumatic psoas, iliac, and lumbar abscesses, of 
which I have seen a number of examples, should 
be opened as soon as discovered. They may be 
distinguished from those which are dependent 
on spinal disease by the previous general good 
health of the patient, by the symptoms coming 
on suddenly after a sufficient injury, and, if any 
doubt remains, by the laudable character of the 
pus. 
I attended with Dr. Morehouse, of Philadel- 
phia, a patient who, on attempting to raise a 
piano while in the stooping posture, felt severe 
and sudden pain within the body, accompanied 
with weakness of the back. The accident was 
followed by continuous suffering in the loins, a 
flexed condition of the thigh, and fever. It was 
our united opinion that a few fibres of the psoas 
muscle had been ruptured, and that probably an 
abscess would be the result. In a few weeks 
this proved to be the case, the abscess presenting 
between Poupart's ligament and the thigh, when 
it was opened, after which the patient com- 
pletely recovered. 
I have seen iliac and lumbar abscesses arising 
from similar causes, and terminating, after their 
discharge, in a like happy manner. 
In cases where disease of the spine is com- 
plicated by the development of coxalgia, the 
patient, if old enough to walk, may wear with- 
out difficulty both the apparatus for angular curvature and that for hip- 
joint disease, as shown in Fig. 1546. 
Fig. 1546. MALFORMATIONS OF THE HEAD FROM EFFUSION. 
885 
MALFORMATIONS OF THE HEAD FROM EFFUSION. 
The malformations of the head are congenital, and in almost every instance 
are determined by dropsy of the ventricles of the brain. When the accu- 
mulation of fluid, by its centrifugal pressure, expands the cerebrum until it 
becomes a thin shell of neurine, the disease is termed hydrocephalus internus. 
When the brain-substance, under the same pressure, yields in a particular 
direction, and is forced through one of the sutures, forming an external tumor, 
it is called an encephalocele. When the medullary and cortical neurine give 
way, in consequence of the increase of ventricular fluid, and the membranes 
or meninges are pushed through between the cranial bones to the outside of 
the skull, the disease is called a meningocele; and should the swelling consist 
of brain-matter and a fluid between the latter and the membranes, it will 
form an encephalo-meningocele. The pathology of congenital ventricular dropsy 
has not been satisfactorily determined. The disease probably begins in the 
choroid plexuses, but whether it is inflammatory or not it is difficult to say. 
Hydrocephalus Interims.-This disease is one of intra-uterine life, and in 
cases where it is thought to have commenced after birth I do not doubt that 
a close scrutiny would have revealed some evidence of its pre-existence. 
The fluid of hydrocephalus is slightly saline, and may be regarded as an 
exceedingly dilute cerebro-spinal liquid, modified in some degree by chronic 
inflammation. The disease, as has been stated, commences in the ventricles, 
and as the fluid continues to increase the brain is expanded, and at the same 
time the cranial bones become separated from one another by the outward 
pressure. (Fig. 1547.) The effect of this centrifugal force is to increase 
the extent of the membrane which occupies the space between the different 
pieces of the cranium, to enlarge the fontanels, and also to diminish the thick- 
ness of the bones. The coronal suture appears to yield most readily, so that 
the antero-posterior or occipito-frontal diameter is most increased: this en- 
largement, the expansion of the head in other directions, the prominent 
eyes, and the comparatively puny size of the bones of the face, which remain 
unchanged, combine to produce the effect of the head of an adult with the 
Fig. 1547. 
Fig. 1548. 
Separation of cranial bones in hydrocephalus. 
Hydrocephalic head. 
face of a child, but with a singular expression of premature maturity. (Fig. 
1548.) The fluid may amount to three or more quarts. The enlargement 
of the ventricles takes place at the expense of the brain, so that in extreme 
cases the neurine almost entirely disappears, or constitutes only a thin per- 
ipheral stratum, the substance of which is so altered as to bear but little 886 
SURGICAL DISEASES OF THE SPINAL REGION. 
resemblance to brain-matter. As a consequence of this, the nutrition of the 
child suffers, the flesh slowly disappearing. There is sometimes loss of vol- 
untary control over the muscles of the body, extending frequently to the 
sphincters of the bladder and the rectum, together with almost utter aboli- 
tion of the mental faculties. Though in most instances the disease proves 
fatal in a year or two, cases are on record where the patient has lived to 
reach adult life. Professor John Neill, of this city, has in his possession the 
skull of a hydrocephalic subject who had lived to the age of forty, and in 
whom the sutures had all ossified. 
Hydrocephalus Externus is not a ventricular disease, but may be associated 
with the latter. It is a collection of fluid in the cavity of the arachnoid 
membrane. It is followed by enlargement of the head, but does not, so long 
as the sutures are not ossified, exercise so destructive an influence upon the 
brain as the ventricular form of the disease. When hydrocephalus begins 
after birth, it is probably of this external variety. Dean Swift is said to have 
labored under this disease; and it is possible that his violent outbursts of 
temper, as well as the eccentricities of his character, and the biting sarcasm 
he so often displayed, were due to cerebral irritation. 
Treatment.-Congenital hydrocephalus rarely, if ever, yields to medical 
or surgical treatment. It is stated by Professor Goltz, of Vienna, that of 
those cases which begin after birth, a majority will recover under proper 
treatment. Those which yield to remedial measures are probably cases ot 
external hydrocephalus and have an acute origin. The only case of the dis- 
ease which I have ever seen recover was one of this last kind. The remedies 
which are employed with the greatest advantage, and which, no doubt, retard 
in some degree the progress of the affection, are mercurial alteratives, such 
as small doses of calomel, administered by the mouth, and the unguentum 
hydrargyri rubbed into the groins and over the inside of the thighs. The 
action of the kidneys should be stimulated by diuretics, and occasionally a 
hydragogue cathartic given. When there is much cerebral irritation, indi- 
cated by involuntary action of the muscles or by epileptic convulsions, the use 
of bromide of potassium will serve to diminish in some measure the excite- 
ment. Pressure has often been resorted to, and can be applied either by an 
encircling or recurrent roller, or by adhesive strips. 
Tapping.-This operation is quite old, having been, it is believed, first prac- 
ticed by Le Cat, in 1774. It has been so uniformly unsuccessful that few 
surgeons recommend the operation at present. Results such as those given 
by Conquest and West have certainly never been obtained in this country. 
The former writer declares that he saved 10 out of 19 cases by tapping; and 
the latter has collected 63 cases of paracentesis for hydrocephalus, 18 of which 
are represented as having been cured. The operation, if undertaken, should 
be performed by a very delicate trocar, which should be introduced through 
the sagittal suture, about one inch behind the anterior fontanel, and to one 
side of the median line, in order to escape the longitudinal sinus. The entire 
amount of fluid present ought not to be drawn at the first tapping, but 
should be removed in installments, and taken at intervals of every ten days 
or two weeks, in order that fatal syncope may not follow the too sudden 
removal of the pressure. As the liquid is withdrawn and the head becomes 
reduced in size, it is advised to maintain the reduction by applying adhesive 
strips about the scalp so as to give support to the diminished walls of the 
cranium. 
Meningocele and Encephalocele.-The initial condition, as has been already 
stated, in the formation of meningocele or encephalocele, is that of ventricular 
dropsy. These protrusions may occur at different localities, but generally are 
found in the occipital region. (Fig. 1549.) I have seen these growths in the 
parietal and frontal regions, and a number of examples are recorded where 
the disease has made its appearance at the root of the nose, at the inner angle MALFORMATIONS OF THE HEAD FROM EFFVSION. 
887 
of the orbit, and at the anterior fontanel. A curious case of protrusion at 
the base of the skull was presented to the London Pathological Society, in 
which the tumor passed into the pharynx by the side of the sphenoid bone 
and extended into the mouth. Its removal was followed by death. 
When the tumor appears in the occipital region, it may pass between 
portions of the occipital bone, or through the foramen magnum, between its 
posterior boundary and the arch of the atlas. Meningocele may be associated 
with a congenital deficiency of some piece of the cranium. In one instance 
of this kind which I saw, the parietal bone was absent, and the protrusion 
occupying its position formed a tumor on the side of the head half the size 
of the cranium. This child lived to the age of ten years, was a pretty, 
bright, intelligent girl, and was in no respect deficient in intellect. The head 
was covered with a dense mass of hair, so that the deformity was not very 
marked. (Fig- 1550.) At the age above mentioned, she fell down a flight 
of stairs, struck upon the tumor, and died in a few hours with marked symp- 
Fig. 1549. 
Fig. 1550. 
Meningocele.-From a patient brought to the Uni- 
versity clinic. 
Absence of parietal bone in meningocele. 
toms of compression. At the autopsy it was discovered that there was an 
absence of almost the entire hemisphere on the side of the meningocele, and 
also that the cavity of the protruding membrane was filled with coagulated 
blood, death having been caused by a rupture of blood-vessels in consequence 
of the fall. 
Diagnosis.-In typical cases of meningocele and encephalocele there will 
be little difficulty in recognizing the true character of the disease. The tumor 
will have a congenital origin, will probably be located in the occipital region, 
and will have a pedunculated connection with the head. Should the contents 
of the swelling be fluid, the test by transmitted light will frequently prove as 
decisive as when applied to a hydrocele. Should the contents be more solid, 
there will be reason for believing the protrusion to be one of encephalocele; 
and if pulsation is present, and on pressure a state of torpor or stupor is 
induced, its central nature is established beyond doubt. There are cases, 
however, in which the diagnosis is not so readily determined, as where the 
tumor appears at unusual localities, is small in size, and where there is some 
uncertainty as to the time of its first appearance. Errors upon this point 
have been committed, and swellings cut into under the supposition of their 
being cysts, which proved to be encephalocele. When, therefore, a tumor 
is observed at the inner angle of the orbit, at the fronto-nasal suture, or in 
the course of other sutures of the head; when it is found to be reducible by 
pressure, disappearing from the surface of the head; and when, in addition, 
there is a history of its being congenital, the intracranial origin of the growth 
may be inferred with certainty. 888 
SURGICAL DISEASES OF THE SPINAL REGION. 
Treatment.-In most cases little more can be done than to apply pressure 
to the enlargement by a cup-shaped shield made of rubber or leathei- and 
moulded neatly to the parts. To defend the skin of the scalp against ex- 
coriation, a thin stratum of cotton can be interposed between the parts and 
the cup, and the whole kept in place by a night-cap. If successful in effecting 
some reduction in the size of the protrusion, the cup should be diminished 
so as to conform to the lessened surface. Cases occasionally occur in which 
the meningocele undergoes a spontaneous cure. A man consulted me in 
reference to a tumoi' over the frontal suture, which had been slowly but 
steadily decreasing in size for a period as long as he could remember, and 
which was doubtless congenital. It had become so small when I saw him 
that it was only when he stooped, or when the head was allowed to hang 
down for a short time, that it would become visible on the surface. The 
gradual ossification of the frontal suture was lessening the space communi- 
cating with the inside of the cranium, and I thought would in time com- 
pletely close it up and cure the meningocele. The cases of meningocele which 
justify a resort to operation are very few indeed. When the protrusion 
grows rapidly, without any general enlargement of the head indicating the 
presence of internal hydrocephalus, the tumor may be tapped with a delicate 
trocar and canula, and afterwards treated by compression. In a case of rapidly 
increasing pedunculated meningocele, hanging from 
the occipital region, which was brought to the Uni- 
versity clinic in 1870, the thought occurred to me 
of gradually dividing the pedicle by means of an 
elastic ring. It was accordingly applied, and by a 
slow process of ulceration the mass was, after ten 
or twelve weeks, separated from the head. (Fig. 
1551.) Shortly afterwards the child died from what 
appeared to be intracranial inflammation. This was, 
so far as I know, the first application of the elastic 
ligature foi' such an object. Iodine has been occa- 
sionally injected with a view to insure a closure of 
the sac. In all cases of meningocele where the 
pedicle is diminishing in size and the growth is 
not increasing, no operation should be attempted. 
Holmes has suggested a plan of operation for me- 
ningocele, as follows: the pedicle is first to be com- 
pressed by a clamp, then the tumor tapped and the 
fluid drawn off, after which the growth should be 
cut off, preserving two flaps of the integument with 
which to close the wound, and after twenty-four 
hours removing the clamp. A novel case of me- 
ningocele has been reported by Dr. Leisure, of Alle- 
ghany City, in which a cure was effected by tapping, 
and afterwards invaginating the walls of the tumors, or turning them back 
upon themselves, so as to occlude the opening in the skull. 
In cases of encephalocele no operation will be proper. Our remedial efforts 
should be confined to giving such support, by means of properly formed 
shields of tin oi' rubber, as will tend to restrain the outgrowth of the mass. 
Fig. 1551. 
Appearances of meningocele after 
removal by elastic cord; showing 
line of separation and section of 
pedicle. CHAPTER XXIII. 
SURGICAL DISEASES OF THE MOUTH. 
In this chapter I shall treat of the surgical diseases of the lips, tongue, jaws, 
gums, teeth, and salivary apparatus. 
LIPS. 
Deformities. 
Contraction of the oral orifice is occasionally met with as a congenital 
condition. More generally it is the result of burns, profuse mercurialization, 
or cancrum oris; and in one case, in a child which came under my observation, 
I believe the contraction was referable to transmitted syphilis. The contrac- 
tion may be so small as to prevent the introduction of food. Even complete 
closure has been noticed. 
Treatment.-When the narrowing is of a character to require surgical 
interference, the principal point to be kept in view in enlarging the opening 
is to preserve a sufficient amount of mucous membrane to cover the raw sur- 
faces of the wound, to the cutaneous margins of which it must be stitched 
by delicate carbolized silk sutures. Silver wire, unless very fine, is too rigid 
for use in such cases. The mucous flaps are preserved by splitting the 
tissues at the sides of the contraction, horizontally, introducing a sharp- 
pointed bistoury flatwise midway between the cutaneous and mucous sur- 
faces of the lips, and dividing them upward and downward for a short 
distance, after which the inner flap is to be divided in two, longitudinally, 
and a V-shaped portion cut out of the cutaneous half. The flaps will present 
the appearance represented in Fig. 1553. 
Fig. 1552. 
Fig. 1553. 
Contracted mouth. 
Cutaneous and mucous flaps joined after removing a V-shaped 
piece from one side. 
Mr. Mason, before enlarging the opening at the commissures of the lips, 
introduces a wire thread at a proper distance from each angle, and, after the 
openings have healed to the condition of a fistula, the parts are divided from 
the openings into the mouth. 
Eversion and Depression.-The cicatrices resulting from burns about the 
neck and face often produce unsightly deformities, drawing down the corners 
of the mouth or causing eversion of the lips. A preternatural length of the 
fraenum labii will also give rise to eversion. 
889 890 
SURGICAL DISEASES OF THE MOUTH. 
Cases of this kind require for their correction the removal of the cicatrix, 
and the substitution of healthy integument taken from an adjacent part. In 
other cases, where the nodular tissue is limited to a portion of the lip, causing 
eversion, the deformity can be corrected by excising a V-shaped piece from 
the entire thickness of the lip, leaving the apex of the V (which must corre- 
spond with the red border) undivided, and afterwards closing the wound with 
hare-lip sutures. If the defect is referable to a long fraenum, the remedy con- 
sists in excising a V-shaped piece from this fold, and permitting it to heal by 
open granulation, in order to obtain the benefit of some cicatricial shortening. 
Chaps and Cracks are frequently observed on the free borders of the lips 
of persons who are much exposed to extremes of temperature, or who labor 
under certain disturbances of the digestive organs. These lesions rarely 
extend deeper than the mucous membrane. They are often very tardy in 
healing, and occasion considerable anxiety by exciting the apprehension that 
the lesion may degenerate into cancer. The lower lip is the one generally 
affected. 
Treatment.-A little cold cream, camphor cerate, or mutton suet applied 
to the affected surface will, in simple cases, be all that is necessary to effect 
a cure. In cases which are more obstinate, an ointment of roses containing 
a little gallic acid will be found useful; or a powder consisting of equal parts 
of calomel and subnitrate of bismuth; or, finally, if these remedies fail, a 
little iodoform may be applied lightly with a camel's-hair brush, and the 
parts afterwards covered with a piece of gold-beater's skin. In habitually 
recurring cases of chaps, the greatest circumspection should be observed with 
regard to the diet, avoiding every article of food which is likely to disorder 
the digestion, eschewing at the same time all manner of stimulants. 
Fissures often appear on the upper lip of children. They are frequently 
attended with an unhealthy discharge from the nose, which excoriates the 
skin below, with tarsal ophthalmia, enlarged glands in the neck, and other 
signs of struma. Cod-liver oil and the syrup of the iodide of iron are the 
remedies for such a condition, the local lesions being only symptomatic of 
the constitutional vice. 
When cracks are observed about the corners of the mouth, a careful in- 
quiry should be made into the case, as it is not uncommon to find such lesions 
in persons suffering from constitutional syphilis. When this is the case, the 
treatment must be antisyphilitic. 
Ulcer.-A neglected chap or crack, or one which has been irritated by 
smoking, is liable to degenerate into a sore or ulcer of considerable depth, 
with irregular edges, and with unhealthy granulations, which bleed on re- 
ceiving any slight injury, as in wiping the mouth, or in chewing the food. 
Using liquid food alone, touching the sore with a crayon of nitrate of silver, 
or stimulating its surface with iodoform and protecting it with gold-beater's 
skin, may serve to insure its repair. But if not, it should be excised and 
the edges closed by the twisted suture. Destructive caustics will also cure 
an unhealthy ulcer of this kind, but they have the disadvantage of leaving 
a depression in the lip, which detracts from its appearance. 
Hypertrophy.-Two forms of hypertrophy of the lip are met with,-one 
involving only the mucous and submucous tissue, and the other all the com- 
ponents of the lip. The upper lip is almost always the one affected. 
Mucous hypertrophy, often called double lip, consists in the formation of two 
semilunar duplications or folds of the mucous membrane of the superior lip, 
one on each side of the median line, which project below, especially when 
the person smiles or laughs. It might be described as a chemosis of the lip. 
(Fig. 1554.) 
The disease begins in a slight transudation from the vessels of the sub- 
mucous tissue, gradually pressing the mucous membrane from the under- HYPERTROPHY OF THE LIPS. 
891 
lying muscular layer, and accompanied by a new formation of intermediate 
connective tissue. 
The subjects of this affection are usually found among those who possess 
a scrofulous organization. 
Treatment.-The treatment consists in in- 
cluding the mucous folds between two elliptical 
incisions, and, after their removal, uniting the 
parts with interrupted sutures made with fine 
silk thread, afterwards keeping the lip covered 
with a pledget wet in cold water. In four days 
the stitches can be removed, by which time the 
union will be found reasonably firm. 
General hypertrophy.-There is a general en- 
largement of the lip noticed in young subjects, 
which is generally associated with a strumous 
organization. There is also a tumid lip, produced 
by causes which interfere with the venous circulation of the head and neck; 
but it is usually associated with a puffy state of the face. 
As the disease does not materially increase with age, it is not desirable to 
make any attempt to retrench the hypertrophied tissues with the knife. 
Alterative remedies, as iodine, iodide of iron, and cod-liver oil, -while they 
will prove of benefit to the general health, exert little influence in reducing 
the local hypertrophy. There is a progressive labial hypertrophy, which 
consists in a large increase of the connective tissue of the part, with marked 
enlargement of the lymph-spaces. I saw a young man, about twenty-four 
years of age, who had this deformity in a very marked degree. The lip was 
dense, leathery, and very prominent. The hypertrophy was removed by 
excising a wedge-shaped piece from the projecting portion and uniting the 
edges of the resulting gap by sutures. 
Fig. 1554. 
Double lip. 
Hair.-Females are often greatly distressed and mortified by the growth 
of an unusual amount of hair on the upper lip. This may take place early 
in life, or it may not be sufficient to attract notice until after forty or fifty. 
There are certain remedies belonging to the class of depilatories which 
will temporarily remove this hair, but it soon grows again, as the piliferous 
follicle is not destroyed. One of the best of the kind, and one which I fre- 
quently employ, consists of one part of sulphide of sodium with three parts 
of prepared chalk, mixed with a little water into a paste and applied to 
the surface covered by the hair. In a few minutes it can be brushed off, 
carrying the hair with it. 
The radical removal of the hair is most satisfactorily accomplished by in- 
troducing a very fine platinum needle into the follicle and connecting it with 
the poles of an electro-galvanic battery. A few can in this way be destroyed 
at each sitting, and, though the process is slow, it has the advantage of being 
sure. 
Moles, with or without hair, occupying the lip, when causing annoyance, 
can be destroyed by applying over their surface a little chloride of zinc paste, 
or, what is still better, if the patient will consent, by excising them and closing 
the wound with a silk suture. 
Wounds of the Lips.-These are incised, lacerated, gunshot, and poisoned. 
Lacerated wounds are the most common, and are produced by hooks, by 
dog-bites, and not uncommonly by the teeth, against which the lips may have 
been driven by a blow. In the latter case it is quite possible to have an exten- 
sive cut on the inside of the lip, without any lesion on the outside. The 
nearer the wTound is to the mucous surface, the more profuse will be the 
bleeding, as the coronary vessels lie immediately beneath the mucous mem- 
brane. 892 
SURGICAL DISEASES OF THE MOUTH. 
Treatment.-All wounds which extend through the entire thickness of 
the lips require for their proper adjustment the twisted suture, in forming 
which the pin must be carried to the depth of the mucous membrane, as only 
in this way can the mouths of the vessels be closed. Ligatures, which inter- 
fere with the quick union of the parts, ought not to be used. 
The scars which attend lacerated wounds of the lips are, from their con- 
spicuousness, to be greatly deprecated, especially as they do not become less 
with advancing years, but, on the contrary, grow with the general growth. 
As an incised wound leaves a much smaller cicatrix than one which is lacer- 
ated, I deem it best to convert a lip-wound of the latter variety into one of 
the former kind by paring away the ragged edges and bringing the sides 
together after the usual manner. 
A lacerated wound which fails to unite from being imperfectly stitched, or 
from the sutures cutting out too early, should be left until all inflammation, 
undue redness, and swelling disappear, when its edges can be freshened and 
brought into contact by means of the twisted suture. 
Gunshot wounds of the lips, like the same class of injuries in other parts of 
the body, will not unite by quick union. They must, therefore, be treated like 
shot wounds elsewhere,-by water-dressings,-and when the sloughs have 
been detached and the granulations have become healthy they may be fresh- 
ened and united. There is often, in these cases of gunshot wounds, ex- 
tensive destruction of the lips, which can be restored only by cheiloplastic 
operations. 
Poisoned wounds of the lips are generally caused by the sting of a bee or of 
some other insect. They are followed by rapid swelling and a burning, itch- 
ing, or pungent pain, which lasts for some hours. 
The repeated application of wet clay, or of a strong solution of bicarbonate 
of soda, will relieve the pain and swelling. 
Carbuncle.-A variety of carbuncle in which the swelling is diffused, hard, 
brawny, and dusky-colored is sometimes seated in the lips. These pecu- 
liarities depend in some measure on the anatomical constituents of the part 
and their arrangement. The disease exhibits a tendency to spread, and is 
often accompanied with alarming symptoms of blood-poisoning. In one in- 
stance I saw a patient die from a carbuncle situated on the upper lip; and 
Dr. Cockle* has recorded a similar case. 
There can be no doubt that in these carbuncular inflammations of the lips, 
as well as those of other parts of the face, there is a degree of malignancy 
which does not belong to the disease when seated in other portions of the 
body. 
Mr. Thomas Smith,f of London, in connection with two fatal cases of car- 
buncle occurring on the face, has thrown out the suggestion that the ten- 
dency to constitutional symptoms may be due to the readiness with which the 
facial veins receive morbid materials. 
Treatment.-The extension of this form of carbuncle is most surely ar- 
rested by free incisions carried down on each side of the diseased tissue, 
after which the parts should be covered with a warm flaxseed poultice ren- 
dered stimulating by being smeared with the compound resin ointment. 
The subsequent local treatment will not differ from that proper in ordinary 
carbuncular disease. 
The constitutional remedies which will be required are iron and quinine, 
opium to relieve pain and restlessness, and stimulants, with the best diet. 
Tumors of the Lips. 
Angeiomatous Naevi.-These vascular formations are frequently situated in 
the lips, particularly the upper lip. 
* Proceedings of the London Medical Society, vol. i. p. 163. Mason, 
f British Medical Journal, p. 22, 1870. TUMORS OF THE LIPS. 
893 
When the disease is limited to the cutaneous surface of the lip, appearing 
as a small red or purple spot, the obliteration of the vessels can often be 
effected by repeated applications of nitric acid or the acid nitrate of mercury, 
or the growth can be destroyed either by excision or by passing a pin beneath 
the spot and surrounding the base with a ligature. 
The more troublesome vascular growths of this nature are those which 
are seated in the mucous surface and those which involve all the tissues of the 
lips. In some the venous element preponderates, in others the arterial, or 
the two may exist in nearly equal proportion. The condition is recog- 
nized by a soft, spongy, vascular mass appearing on the inner surface of 
the lip, having a bluish or purple color, which, in cases affecting the whole 
thickness of the lip, is visible through its cutaneous surface. The tumor 
enlarges during excitement, as in crying or laughing, and can be deprived 
of most of its blood by compression, leaving an apparently empty sac, which, 
however, soon refills on the removal of pressure. These naevi may extend to 
the cheeks. 
As these vascular tumors increase with the growth of the child, the earlier 
they become the subjects of surgical attention the better. There are many 
ways of dealing with these growths, which have already been discussed at 
length. (Vol. i. page 511.) There are three modes particularly applicable 
to angeiomata of the Jip or any part of the face,-ligature, excision, and 
electrolysis. 
The first two are to be used in some of the modes described under the head 
of angeiomata. 
Electrolysis.-In employing the electrolytic method, if the naevus is large, 
two oi' three needles are passed into its interior and connected with the nega- 
tive pole of a battery consisting of seven or eight cells. Another needle is 
then introduced into the growth, and attached to the positive pole. In a 
short time the tissue-destruction which is in progress within the tumor will 
be indicated by little bubbles of gas which make their way by the side of 
the needles. Coincident with this the blood in the growth becomes coag- 
ulated, after which the mass should undergo degeneration and gradually 
disappear. 
Cysts of the lips are caused by the distention of the labial follicles in con- 
sequence of obstruction of the excretory ducts. Very small retention cysts 
may be successfully treated by laying open the sac and turning out the trans- 
parent ropy contents, and cauterizing the cavity with nitrate of silver; but 
when the tumor exceeds the size of a pea, nothing short of excision will 
effect a cure. 
Adenomata.-A new formation of the glandular constituent of the lip form- 
ing a tumor has been observed in very rare instances by Sir William Law- 
rence, Sir James Paget, Mr. Goodhart, and Mr. Mason. In the case men- 
tioned by the last-named gentleman, the growth was said to have been caused 
by a blow received on the lip. The remedy is excision. 
Papillomata, both mucous and corneous, may appear on the lip. 
Mr. Cock,* of Guy's Hospital, London, records a case of a horny growth 
attached to the lower lip; a second is noticed by Dr. A. L. Sawyer;f and 
Professor Grossj; mentions a third, similarly located, and which was five- 
eighths of an inch in length. 
When horny in their consistence, they should be extirpated with the knife; 
when soft, or of the mucous kind, they can be destroyed by either mineral 
or alkaline caustics. 
Myxomata.-Tumors of this class are quite uncommon. Only once have 
* Medical Times, November 8, 1855. f New York Medical Times, 1851. 
J Principles and Practice of Surgery, vol. ii. p. 508. 894 
SURGICAL DISEASES OF THE MOUTH. 
I seen an example of the disease on the lip. This was on the mucous sur- 
face of the lower lip, near the right commissure, in a young lady. It com- 
menced in the submucous connective tissue of the part, forming an oblong 
swelling which extended forward to the junction of the new border with the 
skin of the lip, and was filled with a yellow, gelatinous fluid. The disease 
was cured by excision. 
Fibromata.-Only three or four instances of fibrous tumors of the lips have 
been observed. These have been described as bard, florid, pedunculated en- 
largements, slow of growth, and insensible to pressure. They are to be 
treated by excision. 
Lipomata.-Fatty tumors of the lip are exceptionally rare. I have never 
seen an example of the kind. The lobulated form, doughy fee], and dimpled 
or fissured surface on pressure would establish the diagnosis. 
Foreign Bodies sometimes enter the lip in a singular manner, and remain 
unsuspected for some time, giving rise to indurated tumefactions which have 
been mistaken for carcinoma. Mason has collected three cases in which the 
supposed tumor in each was due to portions of a carious tooth which had 
found their way into the lip, and were discovered only by laying it open. 
Epitheliomata are exceedingly common affections of the lip, and almost 
invariably occupy the lower lip. They are more common in males than in 
females, in the proportion of twenty of the former to one of the latter. The 
disease is most common in middle and advanced life, being rarely seen earlier 
than thirty years. 
Symptoms.-Epithelioma commences generally near the vermilion border 
of the lip, close to the cutaneo-mucous junction, and in one of four w'ays: 
1st, by a localized desquamation; 2d, in a crack or fissure; 3d, in a papil- 
lary or wart-like excrescence; 4th, as a minute, shot-like tubercle. What- 
ever may be the initial appearance, there is always some degree of sub- 
mucous induration discoverable. A scab at length forms, consisting of epi- 
thelial scales mingled with blood, which adheres for a time, and then either 
drops spontaneously or is detached by the finger of the patient, revealing a 
raw, ulcerated surface beneath, which after a time becomes again covered by 
the epithelial debris and unhealthy secretions of the ulcer. This process 
may be repeated for many months, during which, perhaps, there may be 
little uneasiness or pain experienced by the patient, though the area of infil- 
tration continues slowly to enlarge. As the disease progresses, the ulcer en- 
larges ; its edges become hard, irregular, and ragged; fungous granulations, 
which bleed on being handled, and pour out an offensive discharge, overtop 
the lip, and the patient is harassed with sharp, burning, and lancinating 
pains. 
As the work of devastation advances and the 
lip is destroyed, the saliva dribbles constantly over 
the chin and the breast; the disease extends to the 
gums, jaws, and adjacent portions of the cheeks ; 
the glands in the submaxillary and sublingual 
regions become affected; the nutrition fails; the 
sufferer is unable to rest except when under the 
influence of large doses of opiates; his flesh and 
strength fail, until at length, after a year or two, 
worn out by pain and general irritation, death 
comes mercifully to his release. (Fig. 1555.) 
Causes.-Nothing definite is known as to the 
cause of the disease. Little importance is to be 
attached to the alleged influence of the clay pipe used in smoking as a cause 
of this affection, since the number of cases as compared with the number of 
Fig. 1555. 
Epithelioma of the lip. TUMORS OF THE LIPS. 
895 
smokers is too insignificant to give the least credibility to this view. It must 
not be overlooked, however, that the lower lip is much more exposed to irri- 
tation from a variety of causes than the upper lip, and this fact may play no 
inconsiderable part in the causation of the disease. 
Diagnosis.-Epithelioma may be confounded with a benign ulcer, and also 
with syphilitic ulceration of the lip. From the first it can be distinguished 
by the absence of induration, and by the tendency in a simple ulcer to heal 
under appropriate local applications. 
More difficulty will be experienced in at once reaching a satisfactory differen- 
tial diagnosis in cases of ulceration due to a syphilitic origin, as the latter, in 
general appearance, often makes a very plausible counterfeit of epithelioma. 
In both there may be a ragged, destructive ulcer; in both the granulations 
bleed freely; both discharge freely; and in both the glands in the submaxil- 
lary region become enlarged. And yet there are very important differences 
between the two affections: 1st, in the syphilitic disease the ulcer is not 
necessarily confined to the lower lip: it may be on either; 2d, the pain is 
never acute and lancinating; 3d, females suffer as often as males, and the 
young rather than the old; 4th, the patient, notwithstanding the extensive 
character of the ulceration, will probably be strong and robust, and will 
present no evidence of general suffering; 5th, the period between the ulcer 
and the glandular enlargement is rarely more than a few weeks at most; 6th, 
the progress of the ulceration is a great deal more rapid than that of epi- 
thelioma ; 7th, in syphilitic ulceration the odor is far less offensive than that 
of epithelial cancer; 8th, there are present, or have been, other evidences of 
syphilis, which may be ascertained on inquiry. 
Treatment.-The only treatment which promises any safety to a patient 
in a case of epithelial cancer of the lip is an early errcmon. This can be most 
conveniently and expeditiously effected by cutting out, with a sharp-pointed 
bistoury, a V-shaped piece of the lip, including a considerable amount of 
sound tissue along with that which is diseased, and afterwards bringing 
together the sides of the wound with twisted sutures, introducing the first 
pin close to the red border of the lip, and carrying it down to the mucous 
membrane, in order to control the bleeding. (Fig. 
1556.) The extensibility of the lips admits of a 
large amount of tissue being sacrificed without 
materially interfering with the apposition. 
The pins can be removed in twenty-four hours, 
but the union should be supported by adhesive 
strips for a few days following. In many cases 
the disease, when early and properly removed, 
never returns. 
The treatment by caustics has been much 
abused by ignorant and unprincipled pretenders; 
it is altogether more painful and less satisfactory 
than the knife, even when applied by the best 
professional skill, and should be discarded from 
use in this disease. 
After the lymphatic glands in relation with the lip have become enlarged, 
operative interference can promise no good result, and is proper only when 
the object is a short respite from pain, and temporary relief from an offen- 
sive sore. 
Fig.1556 
Operation for epithelial cancer. 
Restoration of the Lips.-In cases of disease or deformity requiring the 
removal of the entire lip, or of so large a portion that approximation after 
the usual manner is impossible, the lost part must be replaced by flaps taken 
from contiguous portions of the face, chin, or neck. These cheiloplastic 
processes, with a little mechanical skill, will remedy the loss of tissue in a 
very satisfactory manner. 
Restoration of the lower lip.-When the lower lip has been cut away from 896 
SURGICAL DISEASES OF THE MOUTH. 
the commissures to the chin, as will frequently be necessary in cases of epi- 
thelioma, the chasm can be filled by resorting to either the Buchanan or the 
Sims operation, the details of the two being very much alike, the only differ- 
ence being that in the former the vertical arm of the incision is curvilinear 
and the horizontal incisions are nearly straight, while in the latter both are 
rounded or curvilinear. I have found it necessary, in my own experience, 
to use sometimes one and at other times the other method, depending alto- 
gether on the extent to which the structures of the chin are involved. 
The plan of Buchanan consists in taking two flaps from the sides of the 
chin, formed by making two incisions, the vertical portion of each being 
slightly oblique, and the horizontal portion straight. (Fig. 1557 will illustrate 
the direction of the incision.) The flaps, being detached, are next raised into 
the site of the original lip, and secured by the twisted suture. (Fig. 1558.) 
Fig. 1557. 
Fig. 1558. 
Portion of lip removed, and lines of incision for the 
formation of a new one. 
Flaps raised into place and retained by pins ready for the 
twisted suture. 
The raw surface from which the flaps are taken is next to be closed by 
sutures. 
Restoration of the upper lip.-In restoring the upper lip the material for the 
raw one must be taken from the face external to the alse of the nose. Sev- 
eral very ingenious operations have been devised for the purpose by Morgan, 
Sedillot, Berard, Dieffenbach, and others. That of Dieffenbach gives, perhaps, 
the neatest appearance. 
Dieffenbach;s operation.-The operation of this surgeon is done by first 
freshening the remains.of the original lip, then raising two S-shaped flaps, 
Fig. 1559. 
Fig. 1560. 
a, lost part of upper lip; b b, flaps on each side of nose. 
Flaps in position and wounds on each side of the al® 
of nose closed by interrupted sutures. 
one from each side of the ahe of the nose (Fig. 1559), and turning them 
across the chasm in front of the alveolus and uniting them together in the HARE-LIP. 
897 
median line, as also to the vivified surface of tissue beneath the nose. (Fig. 
1560.) In cases where the upper lip has been destroyed, a new one may be 
formed by flaps raised from each side of the lower lip, turned across the 
chasm, and united by the interrupted sutures. (Fig. 1561.) 
Fig. 1561. 
Sedillot's method of forming upper lip. 
Hare-Lip.-Hare-lip is a congenital deformity in which the two sides of 
the lip fail to unite. The analogy between this defect in the human lip and 
the normal conformation of the lip of the hare is not strictly correct, as has 
been shown by Geoffroy Saint-Hilaire, the cleft in the latter being exactly in 
the median line, while in the case of the child it is always to one side of the 
centre. The deformity answers, as the same writer states, to the notched 
lip of fishes. It is often associated with club-foot and other congenital mal- 
formations. 
Hare-lip should be studied in connection with fissure of the hard and soft 
palate, and becomes intelligible only when investigated from the stand-point 
of embryology. Anterior to the second month of foetal development, the 
divisions mouth, nose, and pharynx, which we speak of in the child at birth,, 
do not exist, all of these compartments forming a common cavity. These 
cavities are all differentiated-provided no arrest in the process of develop- 
ment occurs to prevent-by the completion of the sixth month of intra- 
uterine life. The palatine plate of the superior maxillary at this time con- 
sists of three parts, separated posteriorly by a median line and anteriorly by 
two diverging lines of sutures. The piece embraced between the anterior 
sutural depressions or fissures is the intermaxillary bone, and bears the in- 
cisor teeth, while in the alveoli of the other two halves are lodged the germs 
of the canine, bicuspid, and molar teeth. The uvula belongs to the palate 
plates of the palate bones, and the upper lip to the alveolar processes of 
the intermaxillary and maxillary bones. When nothing intervenes to dis- 
turb the orderly development of the parts, the horizontal plates of the supe- 
rior maxillary, the intermaxillary, and the palate bones approach one another 
and unite, thus establishing a partition between the nasal cavities and the 
mouth, the arches of the soft palate and halves of the uvula coalesce, form- 
ing a curtain between the mouth and the pharynx, and the upper alveolus 
is completed in front, forming the anterior boundary of the oral vestibule. 
Should, however, some subtle influence prevent the complete closure of the 
posterior extremity of the palatine suture, a cleft would follow. If the 
anterior portion of the same suture fails to close, there remains a more ex- 
tensive cleft, which may also be complicated with non-union of the sutures 
which unite the intermaxillary with the two halves of the upper maxillary 
bone, and, if there is the further deformity of hare-lip, the cleft is complete 
from the outside of the face to the pharynx. 
Hare-lip may be single or double, the defect or fissure being always oppo- 
vol. ii.-57 898 
SURGICAL DISEASES OF THE MOUTH. 
site to the location of the intermaxillary sutures, and, when unilateral or 
single, generally on the left side. 
Single Hare-Lip.-In single or simple hare-lip the cleft generally extends 
upward into the corresponding naris, one side-the inner-of the chasm being 
continuous with the septum narium, and the other, or outer, with the ala? 
nasi, making an uninterrupted communication between the oral fissure and 
the cavity of the nose. The lower margins of the two halves are rounded, 
as is also that of the cutaneous surface of the cleft, but the junction of the 
inner and posterior surfaces is almost rectangular. The mucous membrane 
of the jaw covers both sides of the gap, and the outer half of the lip is 
usually on a plane anterior to the other, and, being the shorter half of the 
two, is much more under the influence of the muscles on that side of the 
face, as are also the alae of the nose, which, by their contractions, serve to 
change the form of the naris and to increase the gap, and in the case of 
adults to cause an unpleasant exposure of the teeth. 
Complications-The complications of single hare-lip are those in which 
the gap is very great, requiring much tension to bring the sides of the lip 
into contact; great deficiency in the sides of the lip; great prominence of the 
bone on the intermaxillary side of the cleft, so that when the approximation 
is made in the operation the corresponding half of the lip is strapped so 
tightly over the eminence as to interfere with its proper nutrition, causing 
the sutures to ulcerate through the tissues before union has had time to 
occur; and, lastly, general malnutrition. 
Time to operate.-On this subject there is some difference of opinion among 
surgeons, some advocating early operations,-and by the term early I mean 
any time between birth and the third month succeeding,-while others prefer 
waiting until after the eruption of the first set of teeth. Personally, I attach 
much more importance to the general health and vigor of the child than to the 
■consideration of age. If the physical condition does not contra-indicate sur- 
gical treatment, the operation may be done at any time after the second week. 
By this time the functions of the organs are well established, and the child has 
acquired vital capital sufficient to resist the shock incident to the procedure. 
The existence of a cleft in the alveolus or hard palate renders an early 
operation desirable, as the traction which follows the union of the lip tends 
to diminish that in the bones. 
In complicated cases of single cleft it is better to wait for four or five 
months. Whatever may have been the experience of other surgeons in cases 
of this nature, my success in early operations has not been encouraging. It 
is hardly necessary to say that during indispositions from primary dentition, 
or from any other cause, no operation will be proper. 
Operation.-The operation embraces the manner of securing the child, 
of freshening or paring the edges of the cleft, of closing the wound, and the 
subsequent treatment. 
Holding the child.-The child, preparatory to the operation, should have the 
arms pinioned to the sides by means of a towel wrapped firmly round the 
body and pinned fast, though not so tight as to interfere with the breathing; 
the latter caution is important in the event of an anaesthetic being adminis- 
tered, which, unless there is some very cogent contra-indicating reason, 
should always be done; its influence need not be kept up any longer than 
during the time occupied in paring the edges of the fissure. 
After the child has thus been secured, it may be laid either on a table or 
across the knees of a nurse, one assistant holding its head steady, while a 
second keeps the body from wriggling and attends to sponging out the blood 
which accumulates in the mouth and pharynx during the operation, for 
which purpose there should be provided small bits of sponge securely fastened 
to wooden handles or locked within the grasp of forceps. 
These preliminaries being arranged, the operator, standing or sitting be- 
hind the head of the child, seizes the lip between the thumb and fingers, HARE-LIP. 
899 
and detaches it from the jaws on both sides of the fissure by dividing with a 
narrow-bladed, sharp-pointed bistoury the labio-maxillary folds of mucous 
membrane preparatory to paring the edges of the cleft. 
There is an invincible tendency in the free borders of vivified tissues to 
become rounded, for nature abhors rectangular forms. The effect of this 
tendency is to leave, after union has been secured between the two sides of the 
hare-lip, a little notch at the bottom or free border, which materially affects 
the good appearance of the patient. To prevent this the ingenuity of oper- 
ators has been taxed to the utmost, and with a result which shows that this 
natural law cannot be satisfactorily contravened. The old form of incision 
is the V reversed. (Fig. 1562.) To obviate this defect, one surgeon makes 
his incisions semi-elliptical (Fig. 1563); another, triangular (Fig. 1564) ; a 
third, with reversed triangles (Fig. 1565); and a fourth uses the parings in 
such a manner that they are not severed at the lower borders of the two 
flaps, but are turned down as two fleshy tongues. (Fig. 1567.) 
Fig. 1562. 
Fig. 1563. 
Fig. 1564. 
Fig. 1565. 
Different forms of incision in hare-lip. 
The design in fashioning the incisions after the different forms described 
is to make the force applied in approximating the margins of the wounds 
operate in pushing out or elongating the parts at the free border of the ad- 
justment. I have practiced all these methods, and am disposed to give the 
preference to two, namely, the double triangle (Fig. 1564) and the one in 
which the parings are preserved below, commonly known as the method of 
Mr. Collis, of Dublin. (Fig. 1567.) In making the lower sides of the tri- 
angles, the lower lines of the figure should be formed well down towards the 
lower borders of the lips, wholly at the expense of the red mucous surface, 
the plan of Clemot and of Malgaigne. (Fig. 1564.) 
To return to the operation. After detaching the lip from the jaw the oper- 
ator pushes the point of the knife through the lip on one side of the cleft, 
and, with a sawing motion, pares away the margin from above downward 
in the angular manner described. The opposite side is to be treated in the 
same manner, and in each instance, before the side of the lip is released from 
the grasp of the surgeon, an assistant presses the cheek between the thumb 
and a finger, external to the angle of the mouth, in order to compress the 900 
SURGICAL DISEASES OF THE MOUTH. 
coronary vessel and prevent bleeding. A clamp may be used for the same 
purpose. 
A third stage consists in the approximation and retention of the sides of 
the wound. This can be done either by the interrupted silver suture or by 
pins and threads. The latter are to be preferred. The objection to the pin 
is the resulting scar; but the pin which I use is very much more delicate 
and longer than the pins generally employed. It is not much thicker than 
the silver thread, has a large glass head, and a very keen point, which pene- 
trates the tissues with the least possible force, and is amply sufficient for the 
purpose of closure. The first pin should be passed across the extremity of 
the wound, just at the junction of the vermilion border with the skin, and 
through the whole thickness of the lip down to its inner or mucous sur- 
face, in order to command the orifices of the coronary arteries. This point 
must not be neglected. A second and sometimes a third pin is to be intro- 
duced in like manner, higher up, while the mucous border is secured by a 
single stitch with a few silk threads, after which the parts are to be drawn 
together by passing figure-of-eight sutures of silk threads. (Fig. 1566.) The 
points of the pins are now to be clipped 
off with pliers, and little strips of plaster 
slid under their extremities to protect the 
skin from pressure, after which additional 
support may be given to the wound and 
the tension on the sutures lessened by a 
few narrow adhesive strips passed across 
the lip from one cheek to the other. 
Before leaving the child, the inside of 
the lip should be carefully examined, to 
see that there is no bleeding. Children 
bear the loss of blood badly. Should any 
leakage exist, it at once excites the child 
to sucking, which favors the hemorrhage, 
and, as the blood is swallowed, a fatal 
collapse may follow without a drop ap- 
pearing externally. 
After-Treatment.-For seventy-two hours after the operation the child 
should be fed with the spoon, sucking having a tendency to interfere with 
the healing. Fretfulness and crying are to be controlled by an occasional 
dose of paregoric or of laudanum. 
Forty-eight hours after the operation the pins may be safely removed, and in 
doing this considerable care is requisite that the wound shall not be torn open. 
The child is to be held very much in the same way as during the operation. 
An assistant presses the cheek together between the thumb and fingers, placed 
on opposite sides, so as to allow no strain on the wound. The surgeon re- 
moves the adhesive strips, and then proceeds to withdraw the uppermost of 
the sutures. This is done by seizing the head of the pin with one pair of for- 
ceps, and rotating it two or three times before using traction, in order to loosen 
its hold, while at the same time, with a second pair of forceps planted astride 
of the pin close to where it enters the flesh, counter-pressure is made, so as 
to prevent any drag on the tender cicatrix. The first suture being removed, 
a narrow strip of plaster is to be placed across the lip before the second su- 
ture is disturbed, after which the other pin or pins can be removed with the 
same precautions. 
The loops which adhere to the surface of the lip, glued to the parts by the 
secretions from the wound, are sometimes allowed to remain, as they still 
play the part of sutures. When this course is adopted, the strips of plaster 
which are drawn over the threads ought to be removed in twenty-four hours, 
and the loops detached; otherwise they are liable to produce excoriation or 
even ulceration of the lip. 
Operation of Collis.-This plan consists in removing from the sides of the 
Fig. 1566. 
Cleft closed by the twisted suture, and point by 
the interrupted suture. HARE-LIP. 
901 
cleft a strip of tissue as low down as the cutaneo-mucous line at the lower 
border of the lip, and then turning the flaps down so that their raw surfaces 
will come together and the two form a teat or protuberance below. (Fig. 
1567.) The sides of the cleft and the flaps below are to be united as in 
the preceding operation, the former 
by the twisted and the latter by the 
interrupted suture. In time the fleshy 
prominence atrophies* and may never 
require any retrenchment, being sim- 
ply a little papilla at the bottom of 
the union. 
The complications which have been 
noticed as offering an obstacle to the 
successful closure of the cleft in single 
hare-lip practically resolve themselves 
into a single one, namely, too great a 
space intervening between the sides 
of the labial cleft to admit of easy ad- 
justment. This must be overcome by 
not only freely detaching the sides of 
the lip from their connection with the 
alveoluh, but possibly by carrying the 
incision round the alse of the nose and separating the corresponding portions 
of the cheek from the bone. As the lateralis nasi artery will be divided in 
so doing, unusual care must be taken to secure the vessels. Another plan, 
devised by Giraldes, consists in making the incisions on each side of the 
fissure, so that by turning the flaps in different directions the gap may be 
closed without tension. An angular incision is made on one side of the lip, 
beginning at its lower free border, and stopping short of its nasal surface, 
the vertex of the angle presenting towards the fissure, and the longest side 
of the triangle being the lower; a second angular incision is made on the 
other half of the lip, beginning above the vertex, directed towards the cor- 
responding naris, and leaving the lower border of the lip undivided. The 
approximation is accomplished by bringing one flap down and the other up, 
the raw surfaces opposing each other in a manner to give an oblique direc- 
tion to the wound. 
Fig. 1567. 
Appearance of the lip after Collis's operation, 
Double Hare-Lip occurs under two forms, the simple and the complicated. 
The simplest variety is that in which there exist two clefts, with an ample 
intermediate piece, without any prominence of the intermaxillary bone, the 
segments of the lip being on the same plane, and the nasal septum not dis- 
placed. There is very little difficulty in managing a case of this kind. 
Operation.-As the middle piece in double 
bare-lip seldom has the same length as the 
sides, it is not possible to make the lo'wer border 
of the three come into line during the approxi- 
mation : so that there are two ways of dealing 
with this intermediate piece. 
First. After dividing the labio-maxillary folds 
of mucous membrane, and paring the four bor- 
ders of the two clefts, the lateral pieces are 
brought together below by the twisted suture 
the middle piece filling up the space above and 
between to the greatest extent possible without 
being stretched. The pins, in passing from side 
to side, penetrate the entire breadth of this 
central piece. (Fig. 1568.) 
Second. Should the lateral portions of the lip be ample and the septum of 
the nose displaced so as to allow its point to sink or become flattened on the 
Fig. 1568. 
Double hare-lip, with lines for paring the 
margin. 902 
SURGICAL DISEASES OF THE MOUTH. 
face, it will be best, after dissecting the intermaxillary part of the lip loose 
from the bone and freshening its lower half, to utilize it as a column on which 
to raise and support the flattened nose, by pushing it up and securing its tip 
in the notch between the lateral portions of the lip. 
The graver and more complicated forms of double hare-lip are those in 
which there is a wide gap in the alveolus, or a great prominence or projec- 
tion of the intermaxillary bone. This piece sometimes stands out almost 
horizontally from the face, 
surmounted by a mere nod- 
ule of flesh. (Fig- 1569.) 
The bone is often connected 
with the nasal septum by a 
small pedicle. (Fig. 1570.) 
How, then, shall this com- 
plication be dealt with ? The 
cleft in the alveolus, indeed, 
that of the whole hard pal- 
ate, which may complicate 
either single or double hare- 
lip, can be markedly dimin- 
ished if the attempt is made 
early, while the bones and 
the attachments are yet plastic, by lateral pressure applied to the cheeks. 
There are three ways in which this can be done: 1st, by the nurse several 
times each day pressing the bones towards the mesial line, by placing the 
thumb and finger on opposite sides of the face over the upper jaw, and 
keeping up firm pressure foi' one or two minutes; 2d, by exerting a similar 
pressure with a truss, such as is sometimes employed after operations, the 
pads of which are to substitute the 
thumb and fingers of the nurse (Fig. 
1571); and, 3d, by a plan recom- 
mended by Dr. Hullihen, of Wheeling, 
West Virginia, which consists in apply- 
ing to each cheek a few strips of adhe- 
sive plaster and uniting their free ends 
across the defective lip by strong silk 
ligatures, which are to be tightened 
from day to day. 
If the sides of the chasm are brought 
together, a permanent union can be 
effected by paring the edges of the cleft 
and holding them in apposition by a 
ligature passed through the bone a short 
distance from each edge of the fissure 
and tying the ends together,-an oper- 
ation first planned by Dr. Fandenberg, 
of Maryland. 
In cases of complication arising from 
a prominent intermaxillary, it is al- 
ways desirable to preserve this bone 
when this can be done without causing 
the defeat of the lateral union. When 
this piece is removed, it is necessarily 
followed by a very unpleasant recession of the lip after the cleft has been 
closed. 
There are three ways of overcoming the obstacle of an unusual projection 
of the intermaxillary bone. 1st. It may be cut away from its attachment 
to the nasal septum. 2d. It may be pressed back into its functional position 
by breaking its connection with the septum. 3d. In addition to being re- 
Fig. 1570. 
Fig. 1569. 
Anterior projection of the in- 
termaxillary bone. 
Under surface of the intermax- 
illary bone, showing the gap be- 
tween the superior maxilla?. 
Fig. 1571. 
Hainsby truss for making pressure on upper 
maxillee. HARE-LIP. 
903 
stored to the intermaxillary chasm, an effort may be made to secure its union 
to the maxillae. 
In the slighter degree of the deformity, and where the attachment to the 
septum is comparatively narrow, the first plan will often fulfill every expec- 
tation. 
The restoration is accomplished after separating from the bone the frag- 
mentary piece of lip, by planting the thumb against the projecting piece, or 
by seizing it with a pair of forceps, the blades being covered with rubber or 
leather, and forcing it directly backward until it sinks into the open space 
behind, after which the different portions of the lip, being pared in the usual 
manner, are brought together in front. Where the base of the intermaxillary 
is broad and strong, it may be necessary to weaken it by cutting out a V-shaped 
piece from its posterior edge before attempting to break it. 
When the intermaxillary is very salient, its attachment formed by a slen- 
der pedicle, and the cleft posteriorly not very wide, the bone should be cut 
away with a pair of bone forceps. Free bleeding from the artery of the 
septum may be expected to follow this procedure, but this can be con- 
trolled either by plugging the orifice of the long canal which contains the 
vessel with a piece of pine wood sharpened to a point, or, what will occupy 
less time, by touching the mouth of the artery with the fine point of a cautery- 
iron. 
Disposing of the bone by reduction, with a view to secure its union with 
associate parts, may be undertaken when the child is vigorous and capable 
of sustaining a prolonged operation and considerable loss of blood. Various 
methods of effecting this have been practiced at different times. A V- or 
wedge-shaped piece can be excised from the septum of the nose and the 
intermaxillary bone forced back into the cavity. (Blandin.) Or a more 
formal operation may be done by not only removing the wedge-shaped piece 
from the septum nasi, but, in addition, paring the intermaxillary piece into 
a shape to fit the cavity and holding the two in contact by a silver suture, 
either passed through both transversely oi' through the septum above, and 
afterwards brought down and twisted below the intermaxillary bone. 
(Braun, Langenbeck.) The last-named surgeon has attempted to substitute 
for the silver thread through the bones flaps of mucous membrane raised 
from the palatine plates of the upper maxillary, and uniting the same across 
the intermaxillary. It would be well, when an operation of this nature is 
done, particularly if the child is not vigorous, to divide the procedure into 
two installments, allowing some time to elapse between, the first being 
limited to the proper disposition of the intermaxillary bone and the second 
to closing the cleft in the lip. 
In all these operations for displacing the intermaxillary bone, either the 
teeth which this piece of the maxilla contains will be lost, or they will, after 
their eruption, have a vicious position and require to be extracted. 
In all cases of failure to secure immediate union between the sides of 
the lip, both in single and in double hare-lip, the parts should be retained 
in as close apposition as possible by adhesive strips, as the cleft may be 
considerably diminished by the union of the granulations in the process 
healing. 
Fissures of the Lower Lip have rarely been observed. Not more than three 
or four instances of the deformity are recorded. The location of those 
which have been noticed was in the mesial line. Should a case of this nature 
be encountered, the treatment would be the same as that required for a cleft 
in the upper lip. 
Commissural Fissures, or Macrostoma.-Several instances of congenital fis- 
sures of the cheek, commencing at the angle of the mouth and running di- 
rectly back towards the ear, or upward in the direction of the malar bone, 
or downward in the direction of the lower jaw, have been recorded by Klein, 904 
SURGICAL DISEASES OF THE MOUTH. 
Lacoche, Nicate, Langenbeck, Fergusson, Gross, and Ashhurst. These defects 
are often associated with other deformities, particularly of the ear. 
The margins of the fissure are to be freshened with the knife, and brought 
together with interrupted sutures. 
Diseases and Injuries of the Tongue. 
Congenital Absence of the Tongue is so rare as to be phenomenal. 
An interesting case of the kind is given by M. de Jussieu, of a young girl 
fifteen years old, whom he saw at Lisbon. She was able to speak with 
entire distinctness, though her words were enunciated slowly. The sense of 
taste was not lost, and the only inconvenience she appeared to experience 
from the defect was some trouble in mastication. 
Adhesion of the tongue to the jaw or to the floor of the mouth has some- 
times been met with. The same writer who notices the case of the tongue- 
less girl mentions an instance of this kind recorded by M. Sernin, of Nar- 
bonne, occurring in an infant, in whom the organ was attached as far forward 
as the tip of the concave surface of the lower maxillary. The tip and mar- 
gins were successfully dissected free, and the child permanently relieved. 
Bands of adhesion sometimes follow the sloughing incident to salivation and 
cancrum oris, and may require to be divided with the scissors or the bistoury. 
Bifid or forked tongues have also been noticed. 
Tongue-Tie consists in a preternatural shortening of the fraenum linguae, 
the little fold of mucous membrane extending so near to the tip of the 
tongue as to prevent the protrusion of the latter beyond the teeth.* The 
physician will often be consulted by anxious mothers with reference to what 
they believe to be tongue-tie in their infants when nothing of the kind exists. 
Whenever a child can carry the tongue sufficiently far forward to touch the 
red border of the lower lip, there is no tongue-tie. The ill effects of a short 
fraenum left undisturbed are experienced both in sucking and, later in life, in 
more or less difficulty in articulating. 
Treatment.-The defect is readily corrected by dividing the shortened 
fraenum and releasing the extremity of the tongue. Simple as the operation 
is, considerable care will be required in its execution, in order that no injury 
may be sustained by the ranine arteries. Numerous accidents of this nature 
have happened, endangering to the last degree the lives of children from 
hemorrhage. A blunder of this kind is easily avoided by not cutting too 
close to the tongue, on the under surface of which the arteries run. 
The operation can be most conveniently done by raising the tip of the 
tongue with the index and middle fingers, placed on either side of the fraenum 
(Fig. 1572), while with a pair of blunt-pointed scissors the restricting bridle 
is snipped, a little nearer to the floor of the mouth than to the under surface 
of the tongue; or the latter can be raised on the handle of a grooved director 
(Fig. 1573), the fraenum slipping into the notch of the instrument, when the 
division can be effected. There is no necessity for making an extensive in- 
cision. A nick to the extent of an eighth or at most a quarter of an inch 
is sufficient. 
There is a certain degree of inability sometimes experienced in raising the 
tongue to the roof of the mouth, to which considerable importance has been 
attached in cases of stammering, and for which division of the anterior fas- 
ciculi of the genio-hyo-glossi muscles was at one time practiced by Dieffen- 
bach. I have performed a subcutaneous myotomy of the anterior part of 
the muscle sufficiently often to satisfy myself that it has nothing whatever 
to do with the defect. I believe at present that it is to be referred to central 
causes affecting the co-ordination of the muscles of the tongue and fauces. 
Among other congenital peculiarities of the tongue which have been noted 
'*• Clarke on Diseases of the Tongue, p. 39. HYPERTROPHY OF THE TONGUE. 
905 
by writers, more curious than instructive, is preternatural mobility of the 
organ. Crosse, of Norwich, mentions the case of a lad who could swallow 
Fig. 1572. 
Fig. 1573. 
Cutting the fraenum in tongue-tie. 
Division of the fraenum while held up by director. 
his tongue at pleasure, and instances have been given where children have 
actually suffocated from a like latitude of movement in the organ. 
Hypertrophy of the Tongue, mentioned by Celsus, is well described by 
Boyer, and also by Percy and Laurent. The writers on the subject in later 
times have been Lassus, Crosse, Paget, Humphrey, Liston, Fergusson, Hodg- 
son, Teale, Maas, of Breslau, Syme, and others.* 
It is generally congenital, occasionally acquired. Females appear to be 
more subject to the disease than males. Clarke has collected 42 cases of 
lingual hypertrophy, 21 of which were in females, 17 in males, and in 4 the 
sex is not given. When acquired, the affection, if not caused by excessive 
mercurialization, or by some antecedent attack of fever or epilepsy, usually 
commences in childhood. The tongue, greatly thickened and elongated, 
Fig. 1575. 
Fig. 1574. 
Hypertrophy of the tongue. 
Hypertrophied epithelial cells observed in hypertrophy of the tongue. 
hangs from the mouth (Figs. 1574 and 1575), there not being room for its 
accommodation within the cavity. In one case related by Clarke, which 
* Transactions of the Provincial Medical and Surgical Association, 1857. Clarke on Diseases of 
the Tongue, pp. 113-134. 906 
SURGICAL DISEASES OF THE MOUTH. 
was operated upon by a surgeon of Stockholm, the organ projected from the 
mouth four inches. 
The teeth are turned out of their usual course, and the lower jaw is 
altered in shape, increasing the space between the incisors and bicuspids of 
the upper and lower maxillae, for the accommodation of the hypertrophied 
organ. The exposed portion, being subjected to various irritants and lack- 
ing the normal pressure of the jaws, increases much more rapidly than the 
part within the mouth, the weight continues to drag the organ still farther 
out, and, with its enlarged papillae giving a warty appearance to the surface, 
and the dribbling of the saliva, it forms a disgusting object. The pathology 
of the affection consists in a new formation of connective tissue, along with 
an unusual development of lymph-spaces, and degeneration of the intrinsic 
muscular structure of the organ. The vascularity of the tongue is also 
greatly increased. 
There is a prolapse of the tongue which is sometimes observed in infants 
and in idiots, which, however, is essentially different from the hypertrophy 
under consideration, being due merely to muscular relaxation, and not to 
structural changes. 
Treatment.-The treatment of hypertrophy of the tongue is by compres- 
sion, excision, and amputation. 
Compression.-In applying compression, which is often a difficult and un- 
satisfactory operation, the tongue, when not too large, may be pushed back 
into the mouth and retained by binding the jaws together with a Barton 
roller. The bandage will require to be removed frequently in order to permit 
of the administration of nourishment and the cleansing of the mouth with 
a solution of myrrh. 
In children old enough to co-operate with the physician in carrying out 
compression, it will not be necessary to take off the bandage oftener than 
once daily, as they will be able to draw a sufficient amount of liquid food 
between the teeth for their support. Or the tongue may be well dusted with 
alum oi' gallic acid, swathed in a piece of old linen, or wrapped firmly with 
either a piece of tape or a narrow gum-elastic bandage. 
Excision.-When pressure fails, it will be proper either to amputate or to 
retrench the tongue by excising a V-shaped portion sufficiently large to re- 
duce the tongue to the proper size, after which the chasm is to be closed by 
bringing its sides together with deep sutures used transversely. 
Of the 42 cases collected by Clarke, to which allusion has been made, 39 
were cured and 3 died. Of the 39 cured, 9 were treated by compression 
alone or aided by lotions, 18 by amputation, 7 by ligature, and 5 by excision. 
The 3 fatal cases, one of which died of pyaemia, one of laryngitis, and one of 
pneumonia, were treated, the first by ligature of the lingual arteries, the 
second by excision and compression, and the third by amputation with the 
ecraseur. This affection is sometimes designated by the terms macro-glossa, 
prolapsus linguae, and lingua vituli. 
Atrophy of the Tongue is much less common than hypertrophy. It may 
be bilateral or unilateral, and is generally connected with some pressure or 
lesion affecting the nerves of the tongue or the centres from which they 
arise. 
This atrophy has been observed as a consequence of lingual paralysis. 
Hughlings Jackson* has reported a case of bilateral atrophy, the sequence of 
hemorrhage into the medulla oblongata, which is a good example of atrophy 
from central lesion. In illustration of atrophy following pressure may be 
mentioned the case given by Sir James Paget, in which a man suffered from 
unilateral atrophy of the organ consequent upon a fall on the back of the head. 
About a year after the accident an abscess formed and a piece of bone was 
removed from the base of the skull, after which the tongue recovered almost 
completely its natural size. 
* London Lancet, Nov. 30, 1872. GLOSSITIS. 
907 
The remarkable case of Dupuytren, in which the atrophy was caused by 
pressure on the hypoglossal nerve by hydatids in the anterior condyloid 
foramen, was not explained until after death. 
Atrophy of the tongue is not necessarily followed by the loss of taste or 
even of sensibility, as is shown by a case of Romberg's. Unless the atrophy 
is the result of pressure from causes which are removable, as in Sir James 
Paget's case, recovery cannot be looked for. 
Glossitis, or inflammation of the substance of the tongue, may arise from 
lacerated or poisoned wounds of the organ, from the injudicious use of mer- 
cury, or from corrosive and other irritating substances taken into the mouth. 
Occasionally it has been seen to appear during the progress of certain erup- 
tive fevers, particularly in hot climates; and it has also resulted from cold. 
Twice have I seen a glossitis follow a wound of the tongue, which in one 
case had been forcibly caught between the teeth, and in the other had been 
torn with a hook. Aggravated cases of glossitis have rapidly ensued from 
the sting of a bee which had been taken into the mouth while eating 
honey. During the reign of mercury, when the drug was used in the most 
reckless manner, swollen tongues from inflammation were by no means 
uncommon. 
I have seen the organ swell so as rapidly to fill the mouth immediately 
after an inadvertent drink of strong lye or of liquor ammonise. 
The inhalation of steam may cause the same inflammatory swelling. De 
la Malle* gives a singular case of a person who, on a wager, attempted to 
eat a live toad. Shortly after the disgusting task had been undertaken, his 
mouth, lips, and tongue became swollen, and the glossitis was relieved only 
by free incisions being made into the tongue. Sir James Paget has noticed 
a case of glossitis following an attack of scarlatina, and Graves, of Dublin, 
another in the person of a medical student who was laboring under a febrile 
attack. 
The rapid swelling which attends glossitis is readily understood when the 
anatomy of the tongue is recalled ; the organ containing very little connec- 
tive tissue, and consequently offering little resistance to the transudation of 
serum and leucocytes. 
Treatment.-The treatment of glossitis must be regulated according to 
the cause. When idiopathic, or arising from constitutional causes, a purga- 
tive, followed by scarification of the organ, or by the application of leeches 
over the submental and submaxillary regions, will be indicated. The mouth 
must be rinsed out frequently with a warm decoction of sage containing a 
little borax or chlorate of potash. The diet should be wholly liquid, as milk 
and beef-tea, and the patient must avoid speaking or using the tongue in 
any unnecessary way. 
Mercurial glossitis requires the frequent use of mouth-washes, the best being 
a solution of chlorate of potash, or a decoction of the berries of the rhus 
glabrum, and internally the administration of the iodide of potassium. The 
gravest cases are those which arise from a poisoned wound, as that inflicted 
by the bee, or from contact of the organ with corrosive acids; in these the 
swelling may be so great as to threaten suffocation, the root of the tongue 
encroaching on the top of the larynx. These require bold and decisive 
measures. 
Two free longitudinal incisions carried into the substance of the organ must 
be made, and usually have the effect of unloading its tissues of the inflam- 
matory transudation and removing the swelling. Any chronic thickening 
which may remain after an attack of acute glossitis must be treated by a 
carefully regulated diet, from which are excluded all hot aromatic substances, 
also wines and all alcoholic beverages, unless the exhaustion of the patient 
demands stimulants, when beer, or ale, or claret should be preferred to liquors 
of heavier body. Tobacco also must be forbidden. The remedies most likely 
* Mem. de 1'Academie de Chirurgie, vol. v. 908 
SURGICAL DISEASES OF THE MOUTH. 
to conduce to the removal of the induration are the iodide of potassium and 
the bichloride of mercury. 
In acute cases of glossitis, when life is threatened from suffocation, it may 
be necessary to open the trachea and introduce a tube, until the urgency of 
the symptoms has passed away. 
Fissured Tongue.-This condition, in which cracks or fissures appear both 
in the sides and over the dorsum of the organ, generally depends on protracted 
derangement of the digestive organs, such as is frequently seen in old dys- 
peptics. It may have a syphilitic origin also. These cracks seldom extend 
far into the tongue, and in mild cases amount to little more than shallow 
grooves between the papillae. 
Treatment.-Neither internal nor external remedies possess much curative 
value, unless accompanied by a diet the articles of which are easily digested, 
and which is rigidly adhered to. The work of digestion will be aided by the 
use of five grains of pepsin at each meal, and by securing daily alvine evacu- 
ations. The repair of the fissures may be promoted by the use of a wash 
of chlorate of potash, of tannin, or of tar-water, and particularly by filling 
up the cracks with subnitrate of bismuth mixed with glycerin and rose- 
water to the consistence of a thick cream. 
Syphilitic fissures must be treated by the iodide of potassium and the 
bichloride of mercury. 
Papillary Disease.-Two morbid affections of the papillae of the tongue 
occasionally come under the observation of the surgeon, which are some- 
times found to be associated with certain squamous diseases of the skin, both 
syphilitic and non-syphilitic, and also with disturbances of the digestive 
organs. 
The milder of the two affections, the psoriasis linguce of writers, appears as 
a white and gray patch of closely aggregated epithelium, traversed by fine 
branching grooves. After a time the patch becomes detached, and there re- 
mains a raw surface having an intensely red color. This process undergoes 
repetition, lasting for years, or the patch may, under some simple application, 
heal up, and be followed by others over different portions of the dorsal sur- 
face of the tongue. When the disease continues for some time, a disorderly 
development of the epithelium and its papillae occurs, which, as the irregular 
patches are thrown off, leaves an ulcerated surface. This more aggravated 
form of the affection is designated ichthyosis linguce; the tongue is subject to 
great variation in appearance, sometimes being coated with a dense fur, at 
other times being almost entirely clean. When the epithelial cells, instead 
of preserving their superficial position, obedient to the laws of desquamation, 
begin to infiltrate or penetrate the lingual papillae, the disease assumes a very 
threatening aspect, and will probably degenerate into epithelial cancer. 
Ichthyosis of the tongue may arise from both local and constitutional 
causes. Glass-blowers are thought by Dr. Andrew Clarke to be especially 
liable to the disease. Others attach much importance to syphilis as a con- 
stitutional cause. 
In the treatment of the disease the influence which the digestive organs 
exert over disorders of the tongue must not be overlooked, and every atten- 
tion must be given to correct any defect which can be traced to this source. 
Arsenic administered internally has been extolled, and if any syphilitic 
infection is suspected it will be proper to resort to remedies suited to combat 
this poison. Should the disease assume a malignant form, amputation alone 
offers any hope of cure. 
Wounds of the Tongue.-The tongue is exposed to the same variety of 
wounds as other parts of the body,-contused, incised, lacerated, punctured, 
poisoned, and gunshot. 
Contusions and slight abrasions, or surface wounds, of the tongue are fre- ULCERS OF THE TONGUE. 
quently produced by the organ being caught between the teeth in falls or 
during an epileptic convulsion, and demand no other attention than the fre- 
quent employment of warm chamomile tea or of warm water containing a 
little borax as a mouth-wash, at the same time using liquid nourishment 
until the parts have recovered. 
Incised wounds are commonly produced by the teeth; sometimes by a 
person falling with a knife placed across the teeth. I have in a number of 
instances seen the tongue almost entirely severed by these means, the two 
parts retaining their connection by a very narrow strip of tissue. 
In both incised and lacerated wounds the parts require to be brought to- 
gether by the interrupted suture. In doing this the patient should be ether- 
ized, in order that the surgeon may have complete control of the organ. Silk 
sutures are to be preferred, and can be passed most satisfactorily by a curved 
needle supported on a holder. 
The stitches should extend either the entire depth of the wound, or, when 
the latter involves the whole thickness of the tongue, they may be applied 
on both aspects of its surface. They should remain five or six days before 
being removed. When a wound of the tongue has been neglected until 
its surfaces are no longer raw, it will require to be refreshened before the 
sutures are inserted. 
Gunshot wounds of the tongue cannot be united by suture, but must be 
allowed to granulate and heal, after which, if the parts admit, they are to be 
pared and brought together like an ordinary wound. 
Punctured and poisoned wounds are dangerous on account of the tendency 
to inflammatory infiltration: when this becomes threatening, one or two free 
longitudinal incisions will be required. 
Abscess of the Tongue is one of the sequences of a localized glossitis, and 
may be caused by contusions, irritants, and cold. It is preceded by soreness 
and swelling in a portion of the organ, followed by shiverings and fever. 
The comparative absence of connective tissue in the tongue favors the diffu- 
sion of the suppuration, which may accumulate, particularly when the abscess 
is near the root of the tongue, so that, together with other products of in- 
flammation, it occasions such pressure at the top of the larynx as to threaten 
suffocation. The disease is liable to be mistaken for simple glossitis, but may 
be distinguished by the tendency in the swelling to point, by a feeling of fluc- 
tuation, and by the history of chills. When the surgeon is not clear in his- 
diagnosis, the introduction of the exploring needle will remove the obscurity. 
The remedy consists in making an opening into the abscess and evacuating 
the contents. 
Sublingual abscess.-There is an inflammation occasionally seen which com- 
mences in the cellular tissue under the tongue, and which tends to displace 
the organ, and when the pus works its way backward it is apt to make 
alarming pressure in front of the epiglottis, occasioning great embarrassment 
to the respiration. These abscesses can be opened either on the side of the 
tongue or in front of the neck beneath the chin. 
Ulcers.-Ulcers of the tongue arise from dyspeptic, syphilitic, parasitic, 
and strumous causes, and from gastric and intestinal disturbances. 
The sore, when from gastric disturbance, is solitary, quite superficial, red 
in color, and seated near the tip of the tongue. 
Treatment.-The treatment of dyspeptic ulcer is attended with much 
difficulty. The patient can rarely be induced to submit to that strict rule 
of self-denial which is absolutely essential to a cure. Under no othei* con- 
ditions can it be healed. 
The cure necessitates abstinence from stimulants of every kind, and from 
the use of tobacco. The diet must consist of bread and milk, eggs, arrow- 
root, tapioca, and animal broths, avoiding the use of meats, aromatics, and 
condiments. Medicine is of little importance. 910 
SURGICAL DISEASES OF THE MOUTH. 
Syphilitic ulceration of the tongue appears in patches, is usually painless, 
increases slowly, and does not affect either the movements of the tongue or 
the articulation. It can be traced to venereal origin, and demands either 
mercury or the iodide of potassium, or both, for its cure. 
Aphthous ulceration, or thrush, is met with both in children and in old per- 
sons. It is not limited to the tongue, but extends to the insides of the cheeks 
and gums. It appears as white flakes, or patches, resembling the curd of 
cheese, some of which remain distinct, while others become confluent. The 
subjacent ulcers are round or oval, surrounded with a red areola, and on the 
bottom of each is a gray, felt-like slough. 
The true nature of the ulceration was first demonstrated by Gruby, in 
1842, as depending on the presence of a fungus,-the 
o'idium albicans. (Fig. 1576.) The spores meet with a 
congenial soil in the mouth, owing to the altered char- 
acter of the secretions of the different glands which open 
into the cavity, and, attaching themselves to the papillae 
of the tongue, grow into a forest of branching filaments. 
Treatment.-When the disease appears in infants or 
children, the physician should institute a strict inquiry 
with reference to the food, and the cleanliness of the ves- 
sels in which it is administered. Nurses are often to 
blame for the existence of the ulceration, administering, 
either from want of judgment or from indifference, food 
unsuited to the stomach of the child, which creates flatu- 
lence and acidity. The correction of any evil from this 
source, the exhibition of a laxative of magnesia, and the 
internal administration of the chlorate of potash, with 
a mouth-wash of the same, will soon effect a cure. In the aged it may be 
necessary, in addition to the use of washes of the chlorate of potash, or of 
carbolic acid, to adopt a general tonic plan of treatment, as the use of iron, 
quinine, and more particularly the mineral acids, with change of air. 
Strumous, or Tubercular Ulcer.-This ulcer is inet with in strumous and 
tuberculous subjects. Its seat is not at all regular, being sometimes located 
on the side of the tongue, at other times near the tip. 
The disease commences in the mucous membrane, in the form of small 
granulations, which after a little time assume a dark appearance, with a yellow 
centre. When the granulations break down, the edges of the resulting ulcer 
are irregular, and its bottom is covered with minute granulations. There is 
also accompanying the sore a notable hypertrophy of the papillae. 
The treatment must be chiefly constitutional, comprising cod-liver oil and 
the iodide of iron, with a nutritious but unirritating diet. The ulcer can 
be touched with advantage every day with iodoform, less frequently with 
chromic acid, or it may be greatly benefited by being dusted with subnitrate 
of bismuth. In the case of a gentleman from California who was under 
my care, and who had two ulcers of this character, one healed under the last- 
named application, and the other, as I subsequently learned by letter, was 
slowly improving. These sores had been open for nearly two years. 
Fig. 1576. 
Oidium albicans. 
The tumors which affect the tongue are benign and malignant. 
The benign tumors are papilloma, angeioma, cystoma, lipoma, fibroma, gum- 
mata, and the malignant carcinoma. 
Tumors of the Tongue. 
Papillomata.-The lingual papillae may become hypertrophied, dense, and 
horny, so as to form a papilloma, or wart. Mr. Hulke has recorded a notable 
Benign Neoplasms. TUMORS OF THE TONGUE. 
911 
example of a patient who suffered from these growths on his tongue, and 
who was in the habit of paring them with a razor when they became too 
long. They are generally free from pain, and slow in their growth. Their 
attachment may be pedunculated or sessile. Excision is the best method 
of removing them. 
Angeiomata.-Erectile or vascular tumors of the tongue are not very 
common. They are seen occasionally seated on the side and dorsum of the 
organ, or near its tip, and may be recognized by their soft, bluish appear- 
ance, and spongy feel. By pressure the blood can be pressed out of the ves- 
sels, leaving the swelling quite flaccid. 
These growths can be treated by strangulation, by excision, by removal 
with the ecraseur or the galvano-cautery, and by injection. 
Strangulation by the ligature is a slow process, and not free from danger 
resulting from the swelling and from the introduction into the system of septic 
matters. In one case which was operated on at the clinic of the University 
by this method, the child was nearly suffocated by the swelling of the tongue, 
and was poisoned by the horrid discharges which exuded from the strangu- 
lated mass. When the growth is small, it is most quickly disposed of by 
excising it, and afterwards closing the wound with one or two sutures. 
When the tumor is larger, the wire or galvanic ecraseur will do the work 
well. In a large naevus covering fully one half of one side of the tongue, 
which came under my care at the Hospital of the University, I succeeded 
in destroying the vascular structure, and converting it into a dense mass of 
fibrous tissue, by injecting into its substance, at five different times, seven or 
eight minims of the tincture of iodine. The interval between the injections 
varied from one to two months. 
Cystomata.-Cysts in the tongue are quite unusual. They are generally 
due to the occlusion of the orifice of a lingual crypt or follicle, though they 
may arise from one of the intermuscular spaces 
of the organ. They are both superficial and 
deep, single and multiple. The tumors are 
usually spherical, the size of a small marble, and 
when they project from the surface, stretching 
the mucous membrane of the tongue, exhibit a 
dull, half-transparent appearance. Fig. 1577, 
taken from one of my patients, represents a cyst 
situated in the middle of the under surface of 
the tongue, near its tip. 
Cystic tumors of the tongue can be laid open 
and the sac excised, or they may be opened, and 
the interior of the sac destroyed by cauteriza- 
tion with nitrate of silver, or by introducing a little ball of lint, and exciting 
suppuration. The first plan, or complete excision, is to be preferred when 
the operation is not attended with too great disturbance of the structure of 
the tongue. 
Fig. 1577. 
Lingual cyst. 
Lipomata.-Fatty tumors of the tongue are exceedingly rare. I have 
never seen a growth of the kind, though a few instances are found in surgi- 
cal writings. 
Clarke notices one in the museum of the College of Surgeons, London, pre- 
sented by Sir Astley Cooper, and another in the museum of Middlesex Hos- 
pital, and Liston refers to a similar one. Should the growth demand surgical 
treatment, the operation by excision would be proper. 
Fibromata.-Fibrous tumors usually occupy the dorsum of the tongue, and 
lie nearer the posterior than the anterior extremity. They are firm, oblong, 
and fixed growths. They grow to the size of an almond before creating 912 
SURGICAL DISEASES OF THE MOUTH. 
much inconvenience. I removed one which had existed for several years 
from the tongue of a young man. The tongue should be dragged forward 
with a tenaculum or a vulsellum, and, while held in this position by an 
assistant, the growth should be seized in a pair of claw forceps, raised up, 
and excised by two elliptical excisions. Deep sutures are to be immediately 
introduced, which serve the double purpose of closing the wound and of 
arresting the hemorrhage. 
Pedunculated fibromata, sometimes spoken of as polypi, are occasionally 
seen growing from the tongue. They appear to elect the posterior portion 
of the dorsum of the organ, just in front of the glosso-epiglottic folds, in 
which to develop. A young woman, under the care of Dr. William Hunt 
and myself, had a pedunculated tumor of this nature, the body of which was 
the size of a walnut, the pedicle being very short. It frequently occasioned 
symptoms of suffocation by falling over on the top of the larynx. It was 
removed by Dr. Hunt by passing a double ligature through the base and 
tying each half separately. 
Enchondromata are the rarest of all growths of the tongue. With the 
exception of two cases, one occurring in the practice of Weber and the 
other in that of Velpeau, I know of none reported. 
The treatment would be excision. 
Gummata of the tongue are indolent, deep-seated, irregular tumors, never 
very prominent, and which, from their immovable nature, appear to be in- 
corporated with the substance of the organ. They are usually free from 
pain, and possess neither the hardness of a fibroma nor the induration of a 
carcinoma. A syphilitic history can always be discovered. The tumor 
sometimes degenerates into an ulcer, which, from its hard, ragged edges and 
unhealthy discharge, might be mistaken for carcinoma. The possibility of a 
syphilitic ulcer being transformed into epithelioma is entertained by some 
writers. I have never seen anything in the history of either affection to 
corroborate such an opinion. 
Treatment.-Gummata yield to antisyphilitic remedies, often leaving, 
after they disappear, a contracted cicatrix. 
Carcinomata.-The epithelial form of cancer is that which in almost all 
cases is witnessed in the tongue, and is generally primary. Males are more 
subject to the disease than females. Of 72 cases which I have analyzed, 40 
occurred in men and 32 in women. Age also exercises a marked influence 
in the development of the disease, the largest number of cases being met 
with between forty and fifty. In only one instance, that noticed by 
Humphrey, has the affection been seen as early as the fifth year. 
Epitheliomata of the tongue are three times as frequent as all the other 
varieties of cancer which affect that organ. 
The progress of the disease is remarkably rapid, few persons surviving over 
eighteen months, and many perishing in six months. Cancer of the tongue 
is usually seated on the side of the organ, rather behind than in front of its 
middle. It begins either as a ragged, hard knot, unyielding to pressure, with a 
substratum of induration, or as a small crack. Very soon after its appear- 
ance the mucous membrane surrounding the base of the knot begins to cor- 
rugate ox* pucker. With these peculiarities the infiltration may progress for 
a considerable time, with or without ulceration, the induration and enlarge- 
ment tending to travel back rather than forward. The disease seldom tran- 
scends the median raphe of the organ, a fact which is probably referable to 
the mechanical obstacle offered by the septum of the tongue to the lateral 
diffusion of the cells rather than to the slight inosculation of the ranine 
Malignant Neoplasms. CARCINOMA OF THE TONGUE. 
913 
arteries. After a time an ulcer forms, having a hard, crisp, elevated and 
ragged margin, with surrounding induration. Soon a rank growth of foul 
granulations, covered with a fetid discharge, springs up, and is frequently fol- 
lowed by profuse hemorrhages from the vessels which open from time to time. 
The glands under the jaw and in the neck become contaminated and enlarge; 
severe neuralgic pains are experienced along the side of the temple and in 
the ear; the mouth becomes so obstructed by the increase in the growth 
that articulation and deglutition are accomplished with difficulty, and the 
pharynx is filled with tenacious mucus and saliva, requiring prolonged and 
repeated efforts for their dislodgment. During sleep the breathing is noisy, 
in consequence of the encroachment of the growth on the fauces and pharynx ; 
the rest is broken, and disturbed with frightful dreams and starts; the strength 
and the flesh waste; the face assumes a sallow or waxy hue; and the hemor- 
rhages grow more frequent, until at length the sufferer dies exhausted. 
Diagnosis.-Epithelioma of the tongue bears some resemblance to syphi- 
litic ulceration, and by those not familiar with the two affections an error of 
diagnosis may be made. The distinction may be established with certainty 
by contrasting the individual characteristics. 
EPITIIELIOMATOUS ULCERATION. 
Commences near the side, and generally behind 
the middle of the tongue. 
Pain sharp, lancinating. 
Movements of the tongue restricted. 
Articulation imperfect. 
Progress rapid. 
Appears at or after middle life. 
Induration precedes ulceration. 
Fetor of discharges very offensive. 
Not influenced by treatment. 
Not necessarily any sign of syphilis. 
Involvement of the lymph glands common. 
SYPHILITIC ULCERATION. 
May occur at any part of the organ, generally 
at the dorsum. 
Little, if any, pain. 
Movements unembarrassed. 
Articulation perfect. 
Progress slow. 
Appears before middle life, as a rule. 
Induration succeeds ulceration. 
Fetor not necessarily present. 
Improves under treatment. 
Always traceable to a syphilitic origin. 
Involvement of the lymph glands not common. 
Treatment.-In a disease which runs its course with such remarkable 
rapidity, and which invariably returns after removal, the question naturally 
arises, Is it proper to recommend an operation ? 
When the induration has extended to the root of the organ, or when the 
floor of the mouth, or the lymph glands beneath the jaw, have become impli- 
cated, any operation contemplating the removal of the tongue is utterly use- 
less, and should be unhesitatingly declined. It is in such cases that the 
operation of dividing the lingual nerve will prove useful by lessening the 
pain and the salivation. This nerve passes between the inferior maxillary 
bone and the internal pterygoid muscle, and enters the tongue just behind 
the submaxillary gland. 
There are two ways of dividing the lingual nerve. The method of Hilton 
consists in incising the mucous membrane on the floor of the mouth, parallel 
with the jaw, and opposite to the second molar tooth, the tongue being at the 
same time drawn to the opposite side. The nerve may be seen immediately 
beneath, when it can be raised on a blunt hook and divided. 
The other method is that of Moore, and may be adopted in the event of 
the floor of the mouth being involved in the disease. This operation is done 
farther back. 
By passing a finger back along the inner side of the inferior maxillary 
bone, the alveolar ridge of the last molar tooth can be distinctly felt. The 
nerve lies behind and parallel with this ridge, between the latter and the 
anterior lateral half-arch of the soft palate. A line drawn from the middle 
of the crown of the last molar tooth to the angle of the jaw, on the inside, 
will cross the nerve about half an inch from the tooth. Accordingly, if the 
point of a curved bistoury is introduced through the mucous membrane, and 
pushed onward in the direction of this line to the distance of three-quarters 
of an inch, and is then turned with its edge to the bone, cutting directly 
down upon the latter, the nerve must be severed. 
VOL. II.-58 914 
SURGICAL DISEASES OF THE MOUTH. 
With a view to restrain hemorrhage and retard the growth of the disease 
by lessening the supply of blood to the organ, the lingual arteries have been 
tied. This operation, first recommended by Dumarquay in 1867, and prac- 
ticed by Hilton and Moore, has also received the sanction of Coote, Hirschfeld, 
and Shrady. The procedure may temporarily check bleeding, but I doubt 
very much whether the patient will be materially benefited. 
In cases of lingual cancer which come early under the notice of the sur- 
geon, before the floor of the mouth or the glands of the neck have become 
implicated, and when the induration has not reached the region of the cir- 
cumvallate papillae, excision of the diseased part, or amputation of the entire 
organ, is a justifiable operation. Justifiable, I say,-not that a cure is to be 
looked for, but because the life of the patient will in all probability be pro- 
longed. 
In an analysis of 39 cases of cancer of the tongue by Clarke, 14 of which 
were treated by operation, the average duration from the commencement of 
the disease was found to be eighty-six weeks, one of the patients living six 
years, while in the remaining 25 who were the subjects of operation the 
average duration of life was about forty-two weeks, and the longest period 
of any one of the number, two years. 
An operation being determined upon, what shall it be? This will depend 
on the extent of the disease to be removed. 
When confined to a very limited part of the tongue, the partial removal 
of the organ may be all that is required; but when more extensive, the com- 
plete or entire ablation of the organ may be necessary. The means of car- 
rying into effect the operation are the knife, the ligature, the ecraseur, the 
galvano-cautery, and the thermo-cautery of Paquelin. 
Knife.-When the disease is near the anterior extremity of the tongue, 
and its size does not exceed that of 
a quarter of a dollar, the knife is to 
be preferred. 
The operation is not very painful, 
and can be done most conveniently 
without an anaesthetic, as the sur- 
geon will have the co-operation of 
the patient's will; though, if the 
latter demurs, there is no serious 
objection to the use of ether. 
The patient being seated on a re- 
clining chair or on a table, with the 
head and shoulders elevated, a gag 
(Fig. 1578) is fixed between the 
molar teeth of one side, in order to 
keep the jaws asunder. 
The tongue is then grasped with 
Museux forceps (Fig. 1579), dragged 
well out of the mouth, and 
given to an assistant to hold, 
when the surgeon, seizing 
the diseased part with a pair 
of claw forceps, removes it 
with a sharp-pointed bis- 
toury by two incisions, one 
on each side, and meeting be- 
hind at an acute angle like 
the letter V. 
Any vessels which bleed must be tied with the animal thread, after which 
the sides of the wound are to be brought togethei' and secured by the inter- 
rupted sutures deeply inserted. 
Ligature.-When the disease is more extensive, or when there is an appre- 
Fig. 1578. 
Gag for separating the jaws. 
Fig. 1579. 
Museux forceps. CARCINOMA OF THE TONGUE. 
915 
tension of hemorrhage, the ligature may be substituted for the knife. The 
jaws being separated by the gag and the tongue 
drawn forward, two needles, armed with stout 
carbolized double threads, are to be passed 
through the sound tissue of the tongue, some 
distance beyond the disease, and the threads tied 
in such a manner as to invest or surround com- 
pletely the affected part, as follows: supposing 
the cancel' is located on the tongue a short dis- 
tance behind its tip, one needle is carried through 
the organ from the under to the upper surface 
in front of the disease, and a second in the same 
manner behind. The silk threads being sepa- 
rated, the different ends are tied strongly to- 
gether, as represented in Fig. 1580. In this way 
the growth is surrounded and the necessary 
strangulation is effected. 
The double ligature, after the plan of Erichsen, 
is also well suited for strangulation. A long 
thread, one half being dark-colored to distin- 
guish it from the other half, is passed back and forth around the diseased 
tissue, after which the loops are to be divided, the white thread on one side 
and the dark one on the opposite side, and their ends tied together. (Fig. 
1581.) 
Fig. 1580. 
Operation by ligature. 
Fig. 1581. 
I have never been very favorable to strangulation by the ligature, as the 
swelling of the tongue which follows, and the presence of a decomposing 
mass of tissue in the mouth, are not free from danger to the patient. 
Ecraseur.-There are three ecraseurs which can be used in removing a 
part or the whole of the tongue,-that of Chassaignac, in which the chain 
loop is used ; that with wires; and that connected with the electro-galvanic 
battery. Any one of these appliances will answer the purpose; but the 
galvano-cautery is particularly well adapted for the ablation, as it can be 
employed without loss of blood. 
Operation by the ecraseur.-When the disease admits of an ecraseur being 
applied to the tongue through the mouth, the operation can be done in the 
following manner: 
If the chain is used, let one of its extremities be . secured to the eye of a 
probe with a loop of silk thread. Then, after dragging the tongue out of the 
mouth with the vulsellum, pass flatwise a sharp-pointed bistoury from the 
under to the upper surface of the organ through the median line. Guided 
by the blade of the knife, let the probe bearing the chain be passed through 
the wound, after which the bistoury is to be withdrawn, the chain pulled 
into position (Fig. 1582), and its ends made fast to the screw of the ecraseur. 
Before commencing the process of crushing, one or two pins should be thrust 
into the tongue from below upward, coming out on the dorsum of the organ 
between the disease and the chain loop, so that the latter shall not, during 
the condensation of the tissues, slip forward into the unsound parts. 
Strangulation by the double thread. 916 
SURGICAL DISEASES OF THE MOUTH. 
As soon as one side is severed, the loop of the instrument can be slipped 
over the other half, and its division effected in a similar manner. If only one- 
half of the tongue is to be removed, two ecraseurs may be employed (Fig. 
Fig. 1583. 
Fig. 1582. 
'Chain and probe passed along the blade 
of the bistoury. 
Removing one-half of the tongue by two ficraseurs; gag 
introduced. 
1583), and operated at the same time, their chains being introduced through 
the same opening. 
In using the wire ecraseur, the loop can be passed very quickly by intro- 
ducing through the tongue a curved trocar and canula, and, upon withdraw- 
ing the latter, carrying the wire through the canal of the instrument, after 
which the canula can be removed. 
Paqueliris thermo-cautery.-Three times I have removed portions of the 
tongue with the knife-shaped instrument of the thermo-cautery of Paquelin. 
In one instance the anterior lateral half was burned off in this manner; and 
in cases where the disease is limited to a small extent of the surface, and not 
far back on the organ, this cautery will be found to act well. 
Total ablation of the tongue.-When it becomes necessary to extirpate the 
tongue in its entirety, the operation may be effected in four ways,-viz., oral, 
symphyseal, submental, and buccal. 
Oral.-The oral method, or that of Paget, consists in separating the lateral 
and anterior attachments of the tongue to the jaw, by dividing the mucous 
membrane forming the floor of the mouth along the sides, and the mental 
origins of the genio-hyo-glossi muscles on each side of the symphysis of the 
lower jaw. When this has been done, the tongue can be drawn out of the 
mouth to an extent which will allow of the hook of the ecraseur being 
slipped back to its root. Mr. Lund adopts the oral method by first getting 
the command of the tongue by means of a ligature passed through its sub- 
stance and cutting away its attachments to the jaw and hyoid bone with 
the scissors, tying the vessels as they are divided. 
Symphyseal ablation, or the method of Syme and of Sedillot, is performed 
by first dividing the lowei' lip in the median line, and carrying the incision 
down to the hyoid bone, and, after removing one of the middle incisors, 
sawing through the symphysis of the lower jaw. 
The two halves of the bone being then drawn asunder, and using the finger CARCINOMA OF THE TONGUE. 
917 
as a guide, the surgeon next divides the attachment of the mucous mem- 
brane along the floor of the mouth, and also the muscles which connect the 
tongue to the jaw, when the lingual arteries are exposed and tied. The 
tongue can now be cut away with the knife, securing any vessels which 
bleed, or its division may be accom- 
plished by the ecraseur. In one in- 
stance, after exposing the organ in 
this manner (Fig. 1584) and sepa- 
rating its attachments from the jaw, 
I threw around its base the wire 
loop of the galvano-cautery, and 
accomplished its bloodless separation 
in a few seconds. 
After the excision has been com- 
pleted, and all hemorrhage con- 
trolled, the two sides of the jaw are 
to be drilled and firmly wired to- 
gether, the lip closed by the twisted 
sutures, and the wound in the neck 
by the interrupted stitch. 
Submental.-There are two operations which may be included under this 
head,-that of Regnoli and that of Nunneley. Regnoli, who published his 
method in 1838, made two preliminary incisions below the chin, one parallel 
with the base of the jaw, stopping short on each side of the facial arteries, 
and the other from the middle of the first down to the hyoid bone. (Fig. 
1585.) The two flaps thus formed are to be dissected back, exposing the 
muscles beneath, which are next to be severed from the jaw, namely, the 
Fig. 1584. 
Operation through the symphysis of the jaw. 
Fig. 1585. 
Fig. 1586. 
Line of incision in Begnoli's operation. 
Tongue drawn out in the submental operation of Eegnoli, 
anterior bellies of the digastrics, the mylo-hyoid, the genio-hyoids, and the 
genio-hyo-glossi. The mucous membrane of the mouth is next detached from 
the jaw with the finger, and divided with the knife anteriorly and laterally 
as far back as the external wound. The tongue is then seized with the vul- 
sellum forceps, drawn through the external wound, and severed from its 
remaining connection, close to the epiglottis and the hyoid bone, either with 
the bistoury or with some form of the ecraseur. (Fig. 1586.) After tying 
any vessels requiring the ligature, the external flaps are to be brought 
together by the interrupted suture, and dressed as an ordinary wound. 
Nunneley's modification.-Nunneley, of Leeds, has simplified the submental 
approach to the tongue, by making a short incision in the median line of the 
neck, between the jaw and the hyoid bone, and continuing the dissection in- 
ward and upward between the genio-hyo-glossi muscles until the mucous 918 
SURGICAL DISEASES OF THE MOUTH. 
membrane of the mouth is reached at the fraenum linguae, being punc- 
tured, the chain or wire of an ecraseur is passed through the opening, slid, 
back over the tongue to its root, and the division accomplished either by the 
screw or by the galvano-cautery, as may be most convenient. (Fig. 1587.) 
As early as 1836, Mirault successfully removed the tongue by opening the 
cavity of the mouth below the chin and introducing through the opening a 
ligature, which was carried far back, and tied around the root of the organ, 
leaving the ends of the cord hanging out of the wound. 
Buccal or Jordan's method.-By this plan an incision is carried from the 
circumference of the mouth on one side to the anterior border of the mas- 
seter muscle. The vessels being tied, the tongue is drawn strongly forward 
and transfixed by two pins, one entering on each side of the fraenum, and 
emerging behind the circumvallate papillae. The loop of the ecraseur being 
now passed over the tongue and behind the pins, the division of the organ can 
be accomplished, after which the wound in the cheek is to be closed by inter- 
rupted sutures. (Fig. 1588.) This operation has been done by Gant with great 
satisfaction, the patient remaining entirely well two years after its execution. 
Fig. 1587. 
Fig. 1588. 
Nunneley's modification for removing the tongue. 
Jordan's method of removing the tongue. 
Whitehead, after amputation of the tongue, deems it advisable to stitch 
the stump to the glosso-epiglottic folds. 
After-Treatment.-After ablation of the tongue, the patient is liable to 
experience considerable difficulty in swallowing, in consequence of the in- 
flammatory swelling. This is best relieved by allowing small bits of ice to 
be taken into the mouth, and by applying hot flaxseed-meal poultices to the 
outside of the throat. Should the swelling threaten to obstruct the opening 
into the glottis, leeches must be applied on the outside of the neck, below and 
behind the angles of the jaw, a brisk purge administered, and a febrifuge 
mixture, with a little morphia, given every two or three hours. When deg- 
lutition is extremely painful, the patient should be nourished for two or three 
days by injections of milk and beef-tea. The mouth-washes most agreeable 
and efficient are the tincture of myrrh, diluted with water, or a decoction of 
rhus glabrum, containing a little borax or chlorate of potash. 
Mortality.-The mortality following the removal of the tongue, considering 
the magnitude of the operation, is very low. Of 76 cases which I have ana- 
lyzed, only 10 died from causes justly attributable to the operation. 
The least fatal operation appears to be that of Nunneley, whose experience 
and success seem to be exceptionally large, he having done the operation 19 
times without a death. 
Nunneley's operation, or that of Jordan, on account of their simplicity, 
and the slight disturbance of the tissues required in their execution, should 
be preferred when the ablation of the tongue is contemplated. The dangers TUMID GUMS. 
919 
incident to the operation are hemorrhage, exhaustion, pyiemia, oedema about 
the glottis, and pneumonia. 
Effect on articulation.-It is remarkable that after the removal of the 
tongue many patients are able to articulate with a distinctness which renders 
them quite intelligible, corroborating in many particulars the wonderful 
stories which are told with reference to persons who have undergone this 
terrible mutilation. Clarke, who has gathered together much curious infor- 
mation on this subject from various sources, mentions the history given by 
Milman of the infliction of this punishment, by the order of a Vandal chief, 
on a number of Christians who resided at Tipasa, on the north coast of Africa, 
during the early part of the Christian era: they were afterwards able to 
speak so well that it was regarded as miraculous. 
By a law of Louis IX. of France, blasphemers and perjurers were con- 
demned to have the tongue burned out with a hot iron. Many French 
Protestants who underwent this mutilation on account of their religion were 
subsequently able to pronounce words distinctly; and it is asserted that 
speech returned to the emirs of Mount Lebanon after they had suffered the 
same punishment as a penalty for conspiring against their chief. 
Diseases of the Gum, Teeth, and Jaws. 
Hypertrophy of the Gums may be either a congenital or an acquired con- 
dition. When the former, it is for the most part associated with some defect 
in mental and also in physical development. 
The hypertrophy is sometimes limited to the soft parts of the gums, being 
a hyperplasia of their normal tissues; at other times, in addition to the 
latter, there is an enlargement of the alveolar process. The disease may 
include the gums of both the upper and the lower jaw, or it may affect only 
a portion of the gum. The latter is usually the case 
when the subject is advanced in life. In typical cases 
of the disease, such as are given by Gross, Salter, 
Waterman, MacGillivray, Heath, and others, the hy- 
pertrophied gum projects as a pale or pink, inelastic, 
rough mass with surface indentations or mammillary 
eminences often overlapping the teeth (Fig. 1589), 
quite insensible to pressure, and giving rise to a very 
marked deformity. 
When occurring in old persons, it is evidently due 
either to the irritation produced by chewing on the 
edentulous gums, or to the pressure of badly-fitting 
artificial teeth. In two instances I have seen an 
extensive hypertrophy arise from the latter cause, 
one in a man of forty and the other in a person of eighty. 
Treatment.-The remedy for hypertrophy, whether congenital or not, 
wThether occurring early in life or late, is excision. The growth may return, 
and require that the operation shall be repeated. In the cases which came 
under my own observation, the enlargement in the younger of the two 
patients required a second removal, which proved to be permanent. 
Fig. 1589. 
Hypertrophy of the gums. 
Tumid Gums.-There are several enlargements of the gums which are 
caused by both local and general conditions of the system. Thus, there is a 
swelling limited to that portion of the gum between the teeth, particularly 
the incisors of the lowei' jaw, and due to the irritation of tartar, which ac- 
cumulates about the necks of the teeth. There is also a swollen, spongy state 
of the gums, which is seen in scurvy and after certain low forms of fever. 
They have a dark red or leaden color, and bleed on being touched. A very 
singular instance of this condition of the gums I once saw in a young lady, 
following an injury to the spinal marrow, to which I have referred under 
the head of injuries to the spinal column and cord. 920 
SURGICAL DISEASES OF THE MOUTH. 
In treating cases which can be traced to local irritation, the removal of 
the irritant is of the first importance, after which, if the hypertrophy per- 
sists, the gums may be frequently penciled with an astringent application, as 
solution of nitrate of silver, tannic acid, or a very dilute preparation of the 
acid nitrate of mercury (one part of the acid to ten parts of water). 
When the enlargement is referable to constitutional causes, iron and qui- 
nine, the mineral acids, with infusions of the bitter tonics, together with a 
varied diet and fresh air, will be required ; should there be a scorbutic element 
in the affection, the vegetable acids will be indicated. 
Mercurial swellings can be readily recognized by the swelling and tender- 
ness of the gums, by the soreness felt on bringing the jaws together, and by 
the flow of saliva and the peculiar fetor of the secretions of the mouth. 
The inflammation, when slight, is quite amenable to a mouth-wash of 
chlorate of potash or of borax. The fetor is best corrected by the use of a 
wash consisting of equal parts of rose-water and tincture of calendula, adding 
to each ounce of the mixture two grains of the permanganate of potash. 
In more severe cases of salivation, in addition to the local remedies already 
named, the internal employment of the iodide of potassium will be found of 
great value. When the teeth loosen and threaten to drop out, and the gums 
are in danger of sloughing, in addition to brushing the parts with the dilute 
tincture of iodine as advised by Garretson, or with salt and brandy, the 
system must be well supported by tonics, stimulants, and nutritious liquids. 
Tartar.-The accumulation of this substance, though occurring chiefly 
as a crust or deposition on the inner surface of the teeth, produces serious 
injury to the gums, and may with propriety be discussed in this connection. 
It is a deposit from the fluid furnished by the salivary glands, and is very 
common in persons who suffer from disturbances of the digestive organs, and 
in those who are indifferent to the use of the tooth-brush. The teeth and 
gums which suffer most are the incisors of the lower jaw and the molars 
of the upper jaw, as these are most exposed to the undiluted saliva as it 
enters the mouth from the sublingual, submaxillary, and parotid glands. The 
depositions of tartar produce inflammation, softening, and even ulceration of 
the gums, and, entering the depressions around the necks of the teeth, event- 
ually cause the latter to become loose, and even to drop out of their sockets. 
A female patient on one occasion applied to me to have a hard tumor re- 
moved from the mouth, which was located between the under surface of the 
tongue and the inferior maxilla. It was completely covered with mucous 
membrane. On making a careful examination, a minute orifice was dis- 
covered on the surface of the enlargement, and on introducing a probe the 
instrument came in contact with a hard substance, which proved to be a 
salivary calculus which had gradually im- 
bedded itself in the mucous membrane of the 
mouth, so as to become completely encap- 
sulated. 
Treatment.-When the tartar docs not ad- 
here tenaciously to the surface of the teeth and 
gums, it may be removed by the tooth-brush; 
but when this cannot be done, it will be neces- 
sary to detach the concretion by means of the 
scaling instrument of the dentist. (Fig. 1590.) To prevent its re-accumula- 
tion, the teeth must be frequently cleansed by a proper tooth-powder applied 
with a soft brush. 
Fig. 1590. 
Dentist's scaler. 
Sloughing Ulcer.-The disease referred to by this term is not that slough- 
ing which arises from the local or constitutional action of certain medicinal 
substances, as mercury, or substances employed in the arts, as phosphorus, 
but an ulcer which appears to depend for its existence on certain zymotic 
causes of too subtle a nature for detection. 
Its subjects are children and the inmates of asylums. Occasionally it is TUMORS OF THE GUMS. 
921 
seen among children who are surrounded by unfavorable hygienic conditions. 
Under the latter circumstances I have seen a well-marked example of the 
disease in this city. It has been observed in the Children's Asylum of the 
Philadelphia Hospital. The disease commences as a dark red, livid, or pale 
spot at the scalloped border of the central incisors of the inferior maxillary. 
The spot darkens, and finally drops out as a slough, when this morbid action 
extends, often very slowly, to the adjacent portions of the gums. The dis- 
charges from the ulcer are sanious and offensive. The destructive process, 
if not controlled, extends beyond the limits of the gums, attacking the al- 
veolar processes, the cheeks, and the lips. 
Treatment.-When the affection makes its appearance in a public institu- 
tion, the children should be removed to other quarters, and those laboring 
under the disease should be separated from the healthy. A wholesome nutri- 
tious diet must be provided, the mouth frequently and thoroughly mopped 
out with solutions of sulphate of iron, sulphate of copper, permanganate of 
potash, bromo-chloralum, tincture of the chloride of iron, or nitric acid, and 
iron and quinine, with milk-punch, administered internally. 
Tumors of the Gums and Pulp-Cavities. 
Under this heading I will describe several varieties of tumors dissimilar 
both in origin and in structure, including those morbid growths of the gums 
technically known as epulides, but which histologically may be classed under 
the different heads of fibromata, fibro-angeiomata, papillomata, myo-fibro- 
mata, and epitheliomata. 
1. Fibrous Growths are frequently seen arising from the gum between the 
teeth, or from other parts of its surface, and are often pedunculated in form. 
They consist chiefly of a hyperplasia in 
the connective-tissue element of the gum. 
(Fig. 1591.) Exposed to friction from 
hard substances in the food and in the 
use of the tooth-brush, these growths are 
liable to bleed and to become a source of 
annoyance and anxiety to the patient. 
Having no connection with the alveolus, 
it is sufficient for their cure that they be 
snipped off close to the gum, and the raw 
surface touched wTith a crayon of nitrate 
of silver. 
Under the head of fibrous growths, 
though not strictly epulides, belong the 
pulp tumors. 
Pulp tumors.-Two tumors of a fungoid 
nature are met with on the gum, which 
have their origin in the pulp of the tooth- 
cavity. The one, which is a hypertrophy 
of the connective tissue of the pulp, is quite 
devoid of sensibility; the other, from its inflammatory origin and its relation 
to the sound nerve-filaments of the alveolus and the pulp, is quite as remark- 
able for its extreme sensibility. Both find their way out of the central canal 
of the tooth, through an opening either in its side or in its crown. The first, 
or callous growth, is generally found in connection with teeth whose cavities 
have been exposed by caries; it assumes a pedunculated form, and, mushroom- 
like, spreads over the tooth and the gum. The second, or sensitive growth, 
has generally a more acute history; it will probably be found to follow 
a fracture of a tooth, and is developed by the sudden access of air, food, 
and other irritants to the dental cavity, causing inflammation of the pulp 
and the formation of a redundant or fungoid mass of granulation tissue. 
Fig. 1591. 
Fibrous tumor of the gum. 922 
SURGICAL DISEASES OF THE MOUTH. 
(Fig. 1592.) The sensibility of this latter growth is so great that the slightest 
touch causes excruciating suffering. 
Diagnosis. - These pulp tumors are 
liable to be confounded with others of a 
more serious nature; but the diagnosis 
may be rendered certain by finding that 
the pedicles of the tumor can be traced 
into the cavity of the tooth. 
Treatment.-Pulp tumors or enlarge- 
ments can generally be cured without 
the sacrifice of the tooth. The affected 
portion of the tooth should be removed and the cavity filled. 
Fig. 1592. 
Fungoid growths from the dental pulp. 
2. Fibro-Angeiomata.-Fibro-vascular growths have two distinct origins, 
-one from the tissues of the gums, and the other from the pulp-cavity of a 
tooth. In the first, or external one, the relative proportion between the 
fibrous and the vascular elements varies. In some the vascular component 
is quite insignificant, while in others it prepon- 
derates to an extent which entitles the tumor 
to rank as an angeioma, naevus, or erectile 
growth. Accordingly, we find such a growth 
appearing sometimes as a florid mass the size 
of a pea, projecting from between the teeth 
immediately above the apex of the scalloped 
borders of the gum, either on its anterior or 
its posterior face (Fig. 1593); at other times 
as a soft, compressible mass, generally on the 
anterior aspect of the gum,-preferably of the 
upper jaw,-having a faint blue or purple color, 
sensibly increased by excitement, and capable 
of being temporarily emptied of its contents by 
pressure. The subjects of these tumors are generally children. Twice have 
I seen them develop at a later period of life. 
The treatment of that form of the disease in -which the fibrous element 
predominates does not differ materially from that proper in cases of true 
fibroma, and should consist in clipping away the neoplasm and cauterizing 
the raw surface left by its removal. There is a probability, however, of 
its return unless the incision is carried deep into the submucous connect- 
ive tissue at its base. Much more serious is the management of the vas- 
cular, oi- erectile, variety of the disease. So intimate is the connection between 
its vessels and those of the bone, that nothing short of the excision of that 
part of the jaw covered by the growth will suffice for its eradication. In 
performing this operation, a preliminary incision should be carried around 
the tumor down to the bone and some distance beyond the limits of the dis- 
ease, after which the piece can be cut away with strong bone pliers. If 
the incisions have been made sufficiently far into the sound bone, the hemor- 
rhage, which at first is quite free, will soon subside. If not, a pledget wet 
with boiling water and then squeezed partially dry can be laid against the 
bleeding surface and will usually check the oozing. 
In a very extensive case of angeioma of the gum which I once saw, the 
tumor extending from the canine tooth to the tuberosity of the superior max- 
illa, the disease was cured by opening the cheek, dissecting awTay the growth 
from the jaw, and sealing up the vessels with the actual cautery. Only the 
slightest superficial exfoliation followed, and the teeth remained firmly in 
their sockets. 
Papilloma of the Gum is a rare affection. It -was first observed by Sir Wil- 
liam Fergusson,* and afterwards described by Mr. Salterf as a white mass or 
growth made up of filiform and fungiform papillae. The remedy is excision. 
Fig. 1593. 
Erectile tumor on the gum of the upper 
jaw. 
* Lancet, September 6, 1862. f Heath, Injuries and Diseases of the Jaws, p. 197, 2d ed. AFFECTIONS OF THE TEETH. 
923 
Epithelioma may develop primarily on the gum, or it may extend to it from 
the lip or the cheek. The primary and secondary forms of the disease differ 
much in appearance. When commencing in the gum, the glands of the latter 
appear to be the seat of the morbid action; the tumor is covered by the un- 
broken mucous membrane, and has been described as a variety of myeloid 
sarcoma. When secondary, or reaching the gum from the lip, jaw, or cheek 
by tissue-continuity, it appears in the ulcerative form with an advancing 
line of induration. 
No operation which does not include the removal of the bone some dis- 
tance beyond the limits of the disease will offer any hope of a cure; and 
even when this is done in secondary epithelioma of the gum, the prospect of 
a cure is exceedingly doubtful. When the lymph glands under the jaw have 
become affected, no operation can afford relief. 
Sarcoma, popularly termed epulis, is a firm, insensitive tumor, covered by 
mucous membrane, and seemingly growing from the posterior margin of the 
gum, or between the latter and the neck of the tooth. Frequently it appears 
to spring from between the teeth, and in most instances occupies the an- 
terior in preference to the posterior face of the gum. (Fig. 1594.) These 
neoplasms vary in bulk from the size of a grain of 
wheat to that of a hickory-nut. The upper jaw is 
slightly oftener affected with the disease than tho 
lower. Females suffer more frequently than males. 
The disease is rarely seen in persons under ten or 
over sixty-five years of age, the largest number being 
met with between twenty and thirty-five. The presence 
of the teeth doubtless has much to do with the causation 
of the disease, as its occurrence in the edentulous jaw is 
quite exceptional. Two varieties of the affection exist, 
one of which is quite firm, and consists largely of parallel 
and intersecting connective-tissue fibres, with which 
occasionally are blended some osseous particles; the 
other is of much softer consistence, with less connective 
tissue, but containing embryonal marrow, or myeloid 
cells, and sometimes the giant polynucleated cells. This would be classified 
with the myeloplaxies by the French school of histologists. 
The first or fibrous variety of the disease springs from the periosteum of 
the alveolus, while the second or softer form probably begins in the endos- 
teum of the cancellated tissue of the alveolus. Not only is the structure of 
the latter rarefied and made porous, but, as the growth occupies the socket 
of the tooth, the cavity becomes enlarged and the tooth finally displaced. 
Treatment.-These tumors, though possessing a tendency to recur, have 
only a local significance. They do not have the malignant properties of 
cancer, and are therefore incapable of producing a cachexia. When they 
have returned after operations done by myself, I have always believed it 
to be due, not to any element of malignancy residing in the growth, but to 
some fault of my own in being too conservative in the sacrifice of structure. 
The treatment, therefore, is clear: let the soft parts be divided down to the 
bone some distance beyond the limits of the tumor, and cut out along 
with the growth an equally extensive section of bone, and the cure will be 
assured. 
Fig. 1594. 
Epulis of the upper jaw. 
Affections of the Teeth. 
The wide range of sympathies exerted by the teeth through the reflex 
system, from the earliest period of dentition until the maxillae become eden- 
tulous in old age, renders their diseases extremely important to the surgeon. 
Much of the gastric and intestinal irritability, convulsions, febrile pertur- 
bations, and skin eruptions of infantile life can be traced to disturbances 
in dentition. It is also true that in more mature life we meet with 924 
SURGICAL DISEASES OF THE MOUTH. 
abscess, caries, and necrosis of the jaws, cases of neuralgia of the face and 
of parts more remote, and of diseases of the eyes and ears, which can be 
traced to morbid states of the teeth. Though oral surgery has assumed the 
importance of a special department, no well-educated physician should be 
ignorant of the diseases which belong to this region of the body; and in- 
deed no oral surgeon is competent to understand the problems of dentition, or 
to treat intelligently the morbid phenomena connected therewith, without 
having enjoyed the advantages of a thorough medical education. 
Inflammation of Gums from Eruption of Teeth.-Although the inflammation 
is due to the advancing tooth or teeth, yet, inasmuch as the general and local 
symptoms depend on the resistance offered by the tissues of the gums, it will 
not be out of place to consider the subject in the present connection. 
When the teeth are sufficiently advanced to render the restraint offered 
by the gum sensible to the little patient, it is indicated by a feeling of itching 
or discomfort, which causes the child to bite upon any hard substance within 
its reach. Often rubbing the gum with the finger will allay the restlessness 
incident to the irritation. After a time the epulic membrane becomes red, 
tender, swollen, and hot, the child is fretful, slavering, and feverish, and not 
unfrequently the reflex irritability is so increased as to give rise to diarrhoea 
or convulsions. 
There are other cases in which all these symptoms may exist and yet the 
gum exhibit no signs of hyperaemia. This fact has suggested to Dr. J. W. 
White an explanation for the disturbances arising from primary dentition 
different from the one already given, namely, congestion of the dental pulp, 
caused by the backward pressure of the resisting gums upon the advancing 
tooth, thus interfering with its nervous and vascular supply. Two papers 
by him on the subject of pathological dentition, one in the Philadelphia 
Medical Times,* and the other in the American supplement to the Obstetrical 
Journal of Great Britain,f will amply repay a careful perusal. 
Treatment.-The proper remedy for this inflammatory and painful condi- 
tion of the gum is incision, commonly called "lancing." This simple opera- 
tion should not be done prematurely. If performed too early, or before 
the tooth has sufficiently advanced, the wound is likely to heal before the 
eruption of the crown, and the resulting cicatrix will at first offer a more 
obstinate resistance to its progress than the original gum. No mistake need 
be committed, however, as the urgency of the symptoms, local or general, 
will serve to announce when the time has arrived for surgical interference. 
The operation is done with the gum lancet. (Fig. 1595.) The child being 
placed across the knees of the 
mother or nurse, with its face ex- 
posed to a good light, and its 
hands held, the operator, seated, 
takes its head between his knees, 
and, separating the lips, exposes 
the offending portion of the gum. 
If over the incisors or cuspids, 
a single incision, parallel with 
the curve of the alveolus, ajid 
sufficiently deep to render sensible to the touch the contact of the blade 
with the underlying tooth, is all that will be required; but when the molars 
are to be released, it will be necessary to make a crucial division of the parts, 
so as to free the four cusps of the tooth. 
With the lancing of the gums the local swelling and inflammation, and 
also the general febrility, usually disappear. 
The bleeding which follows the operation rarely amounts to more than a 
few drops, but should it be profuse it will generally be referable to the hemor- 
rhagic diathesis, and must receive early attention. The wound should be 
Fig. 1595. 
Gum lancet. 
* Philadelphia Medical Times, October 25, 1873. f Op. cit., 1878. IRREGULARITY OF THE TEETH. 
925 
touched frequently with hot alum-water, Monsel's solution of iron, or a 
mixture of equal parts of turpentine, alcohol, and fluid extract of ergot. In 
urgent cases ergot may be administered internally, and, if necessary, the 
actual cautery applied to the bleeding surface. 
Irregularity of the Teeth.-The most common anomaly during second den- 
tition is irregularity of the teeth. They are sometimes crowded together 
in such a manner that the regularity of the dental arch is broken, one or 
several of the teeth assuming an oblique position and their surfaces overlap- 
ping. The difficulty arises from an asymmetrical development of the teeth 
in relation to the alveolar process of the jaw. The remedy consists in the 
judicious removal of certain teeth, generally one or both bicuspids on each side. 
There are instances, again, of irregularity, particularly in the teeth of the 
lower jaw, when the deformity is only slight. The tendency to self-correc- 
tion which is usually present will generally, in time, remedy the evil, and 
the case may therefore be wisely 
left to natural forces. 
When a tooth persists in main- 
taining its vicious position in 
defiance of the laws of develop- 
mental correction, an effort must 
be made to rectify the error. 
Much may be done by systematic 
pressure, made frequently every 
day with the fingers, pushing the 
offending tooth in a direction 
not only opposite to the displace- 
ment, but also outward in the 
long axis of the jaw, so as to in- 
crease the alveolar accommoda- 
tion. If two adjoining teeth, as 
the central incisors of the upper 
jaw, are crowded out of line, 
(Fig. 1596), the traction must be 
applied in opposite directions. While the jaws are in process of development, 
it is astonishing bow much may be accomplished by the unaided efforts of the 
individual. 
Fig. 1596. 
Vicious positions of the central incisors. 
Fig. 1597. 
Fig. 1598. 
Correcting a misplaced incisor by mooring it to a bicuspid 
with an elastic band. 
Plate with silk cords adjusted, to draw incisors into 
position. 
There are other cases of dental irregularity, where, in consequence of the 
solid articulation of the teeth, and the consolidation of the maxilla, nothing 926 
SURGICAL DISEASES OF THE MOUTH. 
short of mechanical measures will answer to restore to place an erring 
member of the dental arch. Among these measures is the adjustment of a 
metal or rubber band (Fig. 1597), or of a plate against the hard palate, to 
which traction cords can be attached. (Fig. 1598.) These are cases which 
require the mechanical skill of the dentist. 
In all these operations for rectifying vicious dental positions, especially in 
young subjects, whether by traction, bands, or wedges, the tendency in the 
teeth to become loose under the force must not be overlooked, and this re- 
quires that the treatment be from time to time interrupted. 
Dental Denudation and Abrasion are terms used to express the gradual 
destruction of the enamel of the teeth, in consequence of which they become 
grooved on the anterior or labial surface, or suffer a progressive loss of sub- 
stance on the cutting or grinding surfaces. 
The incisors are most frequently affected, though all of the teeth may 
undergo a like change. The denudation may commence immediately above 
the necks of the teeth by a softening of the enamel, leaving a well-defined 
groove. Discoloration is frequently associated with denudation. In order 
to prevent the exposure of the pulp, nature, coincident writh the progress of 
the lesion, throws out a deposit of new bone, filling the pulp-cavities of the 
affected teeth. 
The cause of denudation is very imperfectly understood, but it is usually 
either hereditary, or, when acquired, is due to some defect in the function 
of digestion. Mr. Bridgman believes that it is often due to electro-chemical 
agencies; and this view receives the qualified sanction of Garretson. Pecu- 
liarities in the articulation of the maxillse constitute a mechanical cause quite 
sufficient to explain in many cases the occurrence of abrasion limited to the 
grinding or cutting surfaces of one or more teeth. I have specimens in my 
collection of crania which place this beyond cavil. 
Treatment.-When the enamel has, undei' these agencies, disappeared 
from the surface of the teeth near to their necks, the depressions should be 
filled with gold; when the anterior teeth suffer the process of shortening, 
it can be retarded by fitting metal caps to the molars in order to lessen the 
attrition of those affected. 
Dislocation.-A tooth may be loosened from its articulation, or even en- 
tirely displaced, by a blow. It should be immediately readjusted or inserted 
again into the socket, and the jaws bound together until readhesion has been 
contracted. If done promptly and accurately, this may be expected to follow, 
even though some short time has elapsed before it has been replaced. One of 
my medical friends had a large molar extracted, plugged, and afterwards re- 
inserted. A skillful dentist of this city performed a similar operation with 
such success that the tooth has now been doing good service for over two 
years. 
Fracture.-A tooth broken off transversely through the crown, as may 
happen from a fall or a blow in which the violence is received in front, will 
not again unite. Even when broken below the neck, or when fractured 
vertically, it is not possible to secure consolidation of the fragments. But 
when the teeth are not fractured, though torn from the sockets and carrying 
with them portions of the alveolar walls and of the soft tissues, a successful 
reposition is possible. Their careful replacement and retention in position 
by binding the jaws together will generally result in a satisfactory union. 
It is in such injuries that the services of a dentist will prove valuable in 
constructing caps by which the retention of the pieces will be rendered more 
secure. It has happened that the same force which fractures a tooth inflicts 
a like injury on the jaw, and when the latter lesion passes through the 
alveolus belonging to the broken tooth, the union of the jaw may be defeated 
by a root of the injured tooth dropping between the fragments. This hap- DENTAL CARIES. 
927 
pened in a case of Mr. Erichsen, and entirely defeated the consolidation until 
the root was discovered and extracted. 
Dental Caries is an erosion of the dental tissues, commencing in the enamel 
and extending to other portions of the tooth. It begins in a spot or speck of 
discolored enamel, which after a time softens, breaks away, and leaves an 
irregular cavity (Fig. 1599), which continues to enlarge. Unless 
its progress is arrested, the entire crown is destroyed. The roots 
remain, and resist for a long time the destructive process. 
Causation.-The causes which operate to produce caries of the 
teeth have been a fruitful subject of discussion among dental 
pathologists. The teeth are often incorrectly considered as having 
a mechanical rather than a vital connection with the body, and 
as being removed from the influence of those general conditions 
which affect other portions of the human system. If, on the con- 
trary, the teeth are regarded as an integral part of the vital unit, 
subject to the same disturbances of nutrition as other members of the body,, 
it is not difficult to understand the exceedingly common prevalence of dental 
caries, especially among Americans. 
Look at the Irish and Scotch peasants, and see what white and spotless 
teeth these races possess, as compared with the defective teeth which belong 
to the men and women of Philadelphia or any other American city. It is 
not a matter of surprise that American dentists have no equals in the world, 
for where is there such a field for the cultivation of the art as in this coun- 
try ? The chief cause, therefore, of dental caries is not extremes of tem- 
perature, carelessness with regard to cleanliness, the use of sweets, etc. All 
these may exert some influence; but the chief of all causes is one as general 
as the system at large, and is the product of all those agencies which go to 
make up the structure of modern social life, including eating, drinking, 
sleeping, exercise, and education. 
These, too, leave the teeth vulnerable to external irritants which otherwise 
would prove harmless. 
Treatment.-This must be prophylactic and operative. The prophylactic 
treatment will include the use of plain, substantial food, avoidance of alcoholic 
stimulants, exercise in the open air, proper hours for rest, and the use of the 
toothpick, the tooth-brush, and antacid mouth-washes,-none being better 
than a pure article of palm soap, which should be used immediately after each 
meal, as only in this way can the crevices of the teeth be freed from those par- 
ticles of food which through fermentation become the source of destructive 
acids. The operative treatment comes within the province of the dental 
surgeon, and consists in cutting away the diseased tissue until that which is 
sound is reached, and then filling the cavity with a plug of gold, when the 
tooth may be preserved for a long period. 
Fig. 1599. 
Caries of a; 
tooth. 
Necrosis.-Whatever tends to destroy both the vascular pulp and the con- 
nection of the tooth with the periodontal membrane must necessarily pro- 
duce necrosis or death of the tooth, as from these two sources is derived 
its supply of blood. The death of the pulp alone does not produce necrosis, 
although a tooth with a devitalized pulp is frequently miscalled a dead 
tooth. Necrosis may be caused by mercury, by the fumes of phosphorus, 
by scurvy and syphilis, by blows, by a diffused deposition of bone in the 
body of the tooth, and by serious interference with vital functions by the 
various cachexias. 
The death of a tooth is accompanied by a general brown or dark dis- 
coloration of its body, which is often preceded by inflammation of an acute 
or a chronic form, followed by suppuration. Whenever the signs of local 
irritation begin to develop, the tooth should be extracted, as otherwise the 
inflammation may extend to the jaw and cause serious trouble. In aged per- 
sons it is not uncommon to see the teeth loosen and fall out of their sockets 928 
SURGICAL DISEASES OF THE MOUTH. 
without any suffering being experienced. Generally in such cases there is 
a loss of vascularity, the effect of senile atrophy, which involves the gum, 
periodontal membrane, alveolus, and pulp, in consequence of which the parts 
shrink away from the necks and roots and allow the tooth to escape. Ne- 
crosis affects the tooth in its totality, and, once commenced, we have no 
means to arrest its progress. 
Alveolo-dental Abscess, or Gum-Boil.-Alveolar abscess is seated around or 
at the extremity of one or more of the roots of a tooth. It is often the result 
of a neglected or uncontrolled inflammation of the periodontal membrane. 
It is also one of the effects of caries, or may be developed by a tooth being 
crowded in the jaw or by exposure to cold. 
The symptoms which attend the disease are often of a character calculated 
to mislead the inexperienced practitioner. There is a swelling of the cheek 
and of the gum, with tenderness and pain in the jaw, not unfrequently at- 
tended with a paroxysm of fever. The pathology of the disease consists in 
an inflammatory deposition of lymph beneath the periodontal 
membrane, separating the latter from its connection with the root 
and transforming it into a sac. There is also a partial disintegra- 
tion of the end of the root, and between the latter and the thick- 
ened membrane is the cavity which contains the pus. (Fig. 1600.) 
An alveolar abscess finds its way through the wall of the al- 
veolus, and may point immediately external to the affected cavity 
between the jaw and the reflected mucous membrane, forming a 
protrusion of the latter over the gum. 
In other cases, the tissues of the cheek become glued to the 
maxilla?, and the abscess points on the surface of the face. There 
are cases in which the communication between the cavity of the 
abscess and its opening on the surface has a very long and cir- 
cuitous course, terminating in the nasal fossa, particularly when 
an incisor of the upper jaw or a canine is affected. When origi- 
nating at the roots of a premolar or a molar, it may follow the 
hard palate to the fauces, and, if commencing in a tooth of the lower jaw, 
will not unfrequently enter the neck. 
Treatment.-During the acute inflammatory stage of an alveolo-dental 
abscess, it is possible to abort the disease by unloading the congested vessels 
of the gum by free scarifications, followed by a purge, and, after its opera- 
tion, the administration of from two to ten grains of Dover's powder, accord- 
ing to the age of the patient. When no amelioration of the symptoms fol- 
lows, our efforts must be directed to the rapid maturation of the abscess and 
its evacuation at a favorable point. With this object in view, a little bag 
filled with powdered slippery elm and dipped occasionally in hot water may 
be worn with advantage between the cheek and the gum,-never on the out- 
side of the face, as it is not desirable to invite the abscess in that direction. 
Frequent rinsing of the mouth with water alone, as hot as can be borne, will 
conduce to the same end. As soon as the abscess furnishes a hint as to 
pointing, it should be immediately laid open, so that it may not seek the 
external surface. 
There is a stage in the history of an alveolar abscess-just as the acute 
symptoms begin to wane-when, if a little opening is drilled through the 
external wall of the alveolus, the sac may be tapped, the pus evacuated, and 
much suffering avoided. 
An alveolar abscess once formed opens the way for subsequent trouble, and 
suggests the propriety of removing the affected tooth. The exception would 
be when the subject is young and the final dentition not completed, in which 
case even imperfect teeth contribute to the expansion of the jaw. 
Fig. 1600. 
Alveolarab- 
scess at the 
extremity of 
the root. 
Difficult Eruption of the Wisdom-Teeth.-The most alarming symptoms 
often follow the eruption of a wisdom-tooth. The difficulty is a mechanical ODONTALGIA. 
929 
one. The other molars occupy so large a portion of the alveolus that the wis- 
dom-tooth, when it begins to emerge from the jaw, is so crowded back towards 
the root of the coronoid process of the maxilla that it becomes changed in 
direction, and its complete eruption is prevented. The effect of this resistance 
is to develop inflammation of the gum, which is often preceded by a period 
of soreness in the jaw, not suspected for a time to be connected with the 
tooth. In aggravated cases the inflammation extends back to the lateral 
half-arches, to the periosteum of the jaw, and to the soft tissue at the base of 
the tonsils, terminating in suppuration, the abscesses often extending into 
the neck. In the mean time the patient suffers severe pain, with stiffness of 
the jaws, in consequence of the spasmodic contraction of the masseter muscle, 
and experiences great difficulty in deglutition. 
Treatment.-In simple cases, even though the eruption is tardy, if the 
symptoms are not urgent, it may suffice to make free crucial incisions 
across the crown of the tooth and wait for its emergence. But, when there 
is evidence of the inflammatory action becoming diffused, I have seen so 
much evil result from temporizing that I have no hesitation in advising the 
immediate extraction of the tooth. It will sometimes be found difficult to 
get the jaws sufficiently wide apart to gain access to the tooth ; but, by 
administering ether, and prying the maxillae asunder, the forceps can be 
carried sufficiently far back for its removal. 
Dental Fistula.-After the evacuation of an alveolo-dental abscess, a fis- 
tulous track may remain which refuses to heal. The external orifice may 
be on the gum, near the alveolus in which the abscess originated; or it may 
be at some point over the hard palate, or on the surface of the cheek, should 
the abscess have opened originally in these situations. In cases of this kind, 
the irritant which maintains the fistulous canal may be found to be the root 
of a tooth, or possibly a necrosed fragment of the alveolus; occasionally the 
circuitous route of the fistula, or the almost incessant action of the muscles 
of the face, prevents healing. By introducing a probe through the fistulous 
track the length of the passage can be ascertained, and also the presence of 
diseased bone, if any such exists. 
Treatment.-If the tooth or any portion of its roots remains in the socket 
in which the abscess originated, they must be removed at once. This will, in 
most cases, put an end to the fistula. If, notwithstanding, the latter persists, 
the fistulous track should be laid open in its entire extent, and made to 
granulate from beneath. When the external opening is in the face, and it 
refuses to heal after the removal of all detectable causes of the fistula, the 
cheek must be detached from the adjacent parts, the edges of the opening 
freshened, and its sides brought together by the twisted or the interrupted 
suture. 
Odontalgia.-Toothache depends upon a variety of conditions, which, to be 
properly treated, must be clearly understood. 
First. The most common cause of this painful affection is dental caries, 
leaving the sensitive pulp exposed not only to the action of the products of 
bone-decomposition, but to various kinds of external irritation, as air, parti- 
cles of food, and the different secretions of the mouth. Careful and skilful 
examination is frequently required to detect the carious cavity, especially 
when it is located upon laterally opposing surfaces. 
Second. The death and decomposition of the dental pulp constitute another 
cause of toothache, and one which often provokes, in addition, severe neu- 
ralgia of one or more of the branches of the fifth pair of nerves. This is 
attributable to the confinement of mephitic gas consequent upon pulp- 
putrescence producing mechanical pressure. If unrelieved, it eventuates in 
acute alveolo-dental periostitis terminating in abscess. In this condition the 
tooth will be tender to pressure, and the gum unusually red, sensitive, and 
possibly swollen. 
vol. ii.-59 930 
SURGICAL DISEASES OF THE MOUTH. 
Third. Shrinking of the gums, leaving exposed that portion of the tooth 
which is most vulnerable to external agencies, namely, the cementum with 
its periosteum, is not an uncommon cause of odontalgia. This recession of 
the gum-tissues from the neck of the tooth is often the result of a consolida- 
tion of the cementum, which disturbs the vital connection between the gum 
and the tooth, inducing atrophy of the former. When a deposition of new 
bone occurs at the bottom of the alveolus, which may be simultaneous with 
that on the peripheral part of the root, the tooth is raised in the socket at 
the same time that the gum recedes from the neck. 
Fourth. Granular ossification of the dental pulp is another cause of tooth- 
ache, and one very difficult of detection, as there are no local signs which 
betray the changes going on within the pulp-cavity. 
Fifth. Various affections of the jaws, as osteitis, necrosis, osteoma, or cys- 
toma, by inflammatory irritation extending to the pulp, or by pressure on 
the dental nerves, will occasion severe attacks of odontalgia. Cases of the 
disease referable to causes of this kind are usually apparent, not only from 
the coexistence of disease of the maxillee, but from the character of the 
pain, which is seldom confined to a single tooth, and is more continuous than 
ordinary toothache. 
Sixth. Odontalgia is sometimes the result of reflex irritation, traceable to 
sources distant from the seat of pain. In this manner we may account for 
the toothache which occasionally accompanies disorder of the stomach. The 
dental apparatus being a part of the digestive, the two have not only a phys- 
iological but also an anatomical connection through nervous communications. 
Again, pain in one tooth will, in the same way, excite pain in a correspond- 
ing tooth on the opposite side, or in several teeth, which are without any 
evidence of being unsound. Women during gestation frequently are an- 
noyed with odontalgia, which disappears after parturition. 
Gout and rheumatism may likewise occasion odontalgia, in consequence of 
impressions made on branches of the fifth pair of nerves by the products of 
mal-assimilation, which in these affections are not entirely eliminated. 
The young suffer more frequently from toothache than persons in middle 
or advanced life. 
The pain of odontalgia is intense, throbbing, often radiating along the 
branches of the trigeminus to the different portions of the jaw and face, and 
not unfrequently to the ear and eye, and always aggravated by the recum- 
bent position. In other instances the pain, instead of being acute, is dull 
and boring, worrying the patient with its constancy, and frequently accom- 
panied with some swelling of the cheek. This variety is quite common in 
cases where the attack is brought on by exposure to cold, periosteal inflam- 
mation, or gastric irritation. 
Treatment.-The treatment of odontalgia is palliative or radical, and 
must be determined by the nature of the offending cause. 
The palliative treatment will embrace the correction, by acid or alkaline 
washes, of any defective reaction in the secretions of the mouth, and the 
removal, in the event of a cavity existing in the tooth, of any irritating 
substances. 
When caused by exposure or near exposure of the pulp, direct applications 
to the cavity of decay will generally abate the pain. Among the best of the 
remedies are acetate of morphia (made into a paste with creasote, oil of 
cloves, or glycerin), oil of cloves, creasote, carbolic acid, laudanum, and tinc- 
ture of aconite. A dossil of cotton should be moistened with one of these 
agents and inserted without pressure into the cavity of the tooth, and covered 
with a little wad of cotton to hold it in place. 
Dr. Garretson extols the use of a solution of sulphate of atropia in cases 
which arc not associated with inflammation of the dental tissues or of the 
surrounding parts, of the strength of six grains of the alkaloid to one ounce 
of water, and applied in the same way as the remedies already designated. 
The poisonous character of the drug, however, renders it unsuitable for gen- ODONTALGIA. 
931 
eral use, and it should be employed only under the immediate supervision of 
the physician. 
The patient should be directed, after the insertion of any of the more 
powerful agents, not to swallow the saliva for a time. 
When the trouble is located in the periosteum, the measures best calculated 
to afford relief are the scarification of the gums when they are swollen and 
inflamed, the tincture of camphor or of hamamelis held in the mouth, the 
frequent use as a mouth-wash of water as hot as can be borne, which may 
be medicated by adding to it a few drops of laudanum, and a spice plaster 
worn over the cheek or between the cheek and gum over the affected tooth. 
To these palliative resources may be added, when there are symptoms of 
gastric disorder or of cold, the administration of a saline purge, followed by 
a hot bath on going to bed, and a dose of spiritus Mindereri to which may 
be added an amount of morphia suited to the age of the patient. 
When the toothache is due to death of the dental pulp or to its granular 
ossification, the remedy lies either in the extraction of the tooth, or, what is 
better, in drilling an opening into the pulp-cavity, either through the wall of 
the tooth, or through the cavity of decay if one exists. 
The radical treatment of odontalgia requires either the sacrifice of the 
tooth, the cure of abscess, or the devitalization of the pulp, and filling the 
remaining cavity with a suitable plug. This can be done only by one familiar 
with the duties of operative dentistry. 
Extraction.-The extraction of a tooth is a very delicate operation, and 
demands both manual skill and scientific judgment. Carelessness in this re- 
spect has too often resulted in irreparable damage to the jaw and has been 
followed by extensive abscesses of the neck. 
Circumstances demanding extraction.-The reduction of the food to a state 
suitable for insalivation is so important a factor in the work of digestion, 
that no tooth ought to be sacrificed which can be safely preserved. I 
shall, accordingly, name those conditions which usually doom a tooth to 
extraction : 
1st. When its body has been so extensively destroyed by caries as to leave 
only a shell so thin as to be unequal to sustaining the pressure of a filling, 
or when one or more of its roots remain in the socket and cause irritation. 
2d. Teeth from the cavities of which grow fungous excrescences, sometimes 
called polypi of the pulp. 
3d. Teeth in a jaw overcrowded. 
4th. Teeth with alveolar abscess not otherwise curable. 
5th. Wisdom-teeth wThich threaten to cause abscess. 
6th. Teeth which have become hopelessly loose either from traumatic or 
other causes. 
7th. Teeth which, in consequence of osseous tumors or ossification of the 
dental pulp, give rise to facial neuralgia. 
8th. Teeth which, from their vicious position in the dental arch, so change 
the bearing of the crowns of the others as to cause their surfaces to grind 
away. 
Instruments.-In order to remove a tooth properly from its socket, it is 
necessary to have instruments adapted to the anatomical conformation of 
its surface; or, what amounts to the same thing, to the class to which it 
belongs. 
The incisor teeth, having a bicuneiform shape, the bases of the wedges 
going within the grasp of the gum, require an instrument the jaws of which 
will adapt themselves to a portion of both the alveolar and crown planes of 
the wedge, in order that it may not slip wThen the force is applied. The for- 
ceps represented in Figs. 1601, 1602, 1603, and 1604 furnish the best examples 
of instruments suited to the extraction of the incisors of the upper oi' lower 
jaw. 
For removing an upper or lower bicuspid, or a canine, the forceps shown 
in Figs. 1605, 1606, and 1607 are valuable. 932 
SURGICAL DISEASES OF THE MOUTH. 
For extracting the molar teeth of the upper and lower jaw, Figs. 1608 and 
1609 furnish the best patterns. 
Fig. 1601. 
Fig. 1602. 
Forceps for extracting upper incisors. 
The old instrument for removing teeth, which consisted of a semicircular 
key attached to a shank with a handle, has, very properly, fallen into desuetude. 
Fig. 1603. 
Forceps for extracting lower incisors or bicuspids either side. 
Forceps for extracting lower incisors. 
Fig. 1605. 
Forceps for tipper bicuspids or canines. 
As the tissues of the gum through the periodontal membrane are closely con- ODONTALGIA. 
933 
nected with the neck and root of the tooth, these should be freely separated 
Fig. 1606. 
Forceps for extracting bicuspids and canines of either jaw. 
Fig. 1607. 
Forceps for extracting lower bicuspids. 
from the latter, preliminary to extraction, by means of the gum lancet. (See 
Fig. 1595.) 
The pain which accompanies the extraction of a tooth firmly imbedded in 
Fig. 1608. 
Fig. 1609. 
Forceps for extracting molars. 
its alveolus is of the most intense character, and, if of long continuance, 
would be unbearable. 
The extraction of teeth, however, has been deprived of all its terrors by 
the use of anaesthetics, which should not be withheld unless at the special re- 
quest of the patient. The operation being usually a brief one, nitrous oxide 
gas should have the preference over all others. When chloroform is given, 
the patient must occupy the recumbent position. 
Local anaesthesia is sometimes practiced in order to lower the sensibility 
of the parts concerned in extraction. It is induced usually by agents which, 
by rapidly abstracting the heat of the gum and the jaw, render the nerves 
partially insensible to painful impressions. With this object in view, the 
parts may be surrounded with a thin gum bag or bladder containing a mix- 
ture of ice and salt, or they may be subjected to the action of a spray of 
ether or rhigolene, applied by means of the ordinary hand or foot apparatus. 
(Fig. 1610.) 934 
SURGICAL DISEASES OF THE MOUTH. 
Operation.-If the operation is done at the office of the dentist, the patient 
occupies a chair with a high back and head-rest, purposely constructed for 
dental manipulations, and be- 
hind which the operator stands, 
supporting the head of the pa- 
tient between one hand and 
the side of his body, while with 
the other he holds the extract- 
ing forceps. When the opera- 
tion is performed in the office 
of the general practitioner, or 
at the house of the patient, the 
latter should be seated on a 
low chair, and bis head sup- 
ported either by an assistant 
standing behind, or by the 
physician, who takes it be- 
tween his arm and body. The 
gum being then freely divided, 
the operator seizes the tooth 
between the jaws of the for- 
ceps, close on a level with the 
alveolus, and proceeds to re- 
move it from the jaw, by first 
using the instrument as a lever 
in which it is carried alter- 
nately inward and outward, 
combined, in the case of the 
incisor teeth lodged in a round 
conical pit, with a movement 
of rotation, in order to break 
the articulation between the 
root and the socket, when it 
becomes loose; after which 
traction is applied by which 
the tooth is lifted from the al- 
veolus. The process is in all 
respects analogous to that by 
which one extracts a nail that 
has been driven into a piece of 
board, by forcing it backward 
and forward until it becomes 
loose, and then by pulling it 
directly out. 
In extracting molar teeth 
with roots which widely diverge, the articulation with the alveolus may be 
broken, first on one side and then on the other, before applying traction. 
This manoeuvre will conduce to the safety of the jaw. 
In removing a wisdom-tooth which has only a single root, and which is 
crowded back towards the ramus of the jaw by the neighboring molar, it 
should be moved backward before making traction, in order not to endanger 
the solidity of the adjacent tooth. 
Teeth are sometimes broken off during attempts at extraction, leaving the 
roots in the alveolus, or all above the latter may have been previously de- 
stroyed by caries, the roots alone remaining in the sockets. The extraction 
of such roots requires instruments of a different form from those ordinarily 
employed in removing entire teeth. For this purpose forceps with a thin, 
narrow beak (Fig. 1611), which can be slipped down between the root and 
the sides of the socket, will be required. 
Fig. 1610. 
Spray apparatus. ODONTALGIA. 
935 
Sometimes when difficulty is experienced in obtaining command of the 
root, in consequence of failing to get the forceps down, it may be removed 
Fig. 1611. 
Narrow-bladed forceps for extracting roots. 
by means of the screw elevator. (Fig. 1612.) This instrument, after being 
bored into the central cavity of the stump until it acquires a good hold, is to 
be drawn upon until the root is extracted. 
Fig. 1612. 
Screws for extracting roots. 
Another plan of extracting these roots, especially those belonging to molar 
teeth and which refuse to yield to ordinary measures, is to divide them in 
half by the cutting pliers (Fig. 1613), when they may be removed, each piece 
separately, by the ordinary root forceps. 936 
SURGICAL DISEASES OF THE MOUTH. 
Accidents following extraction.-In removing a tooth, the roots may be 
Fig. 1618. 
Cutting and elevating pliers. 
very divergent, or there may be some malformation, such as fusion of the 
roots (Fig. 1614), so that a portion of the alveolus is broken away. 
When only a small fragment is detached, the accident is seldom 
followed by any evil; but where the injury has been more exten- 
sive I have seen a wide-spread necrosis of the jaw follow. When 
the connection between the fragment and the alveolus is not en- 
tirely destroyed, it should be replaced and given a chance to regain 
connection with the bone; but if too completely detached to render 
such a result probable, it will be best to clip away any slight 
attachments which remain and remove it. 
Hemorrhage.-There is always, after the extraction of a tooth, 
a brisk flow of blood ; but this generally ceases after a few minutes. Occa- 
sionally, however, cases are encountered in which a very alarming hemor- 
rhage follows the operation. There is probably, in most instances of this 
nature, a pre-existing hemorrhagic diathesis. 1 have seen dangerous bleed- 
ings after extraction in persons with mitral disease of the heart or with 
Bright's disease. 
In treating a case of alveolar hemorrhage, the cavity from which the tooth 
has been extracted should be thoroughly mopped out and inspected, in order 
to discover the source whence the blood proceeds. If from a single point, 
it is probably limited to a small artery, and may be at once checked by 
sharpening a piece of soft pine wood to a fine point and thrusting it into 
the aperture through which the blood issues. When the oozing is general, 
or from several points, the socket must be firmly plugged with a piece of 
sponge previously well saturated in a hot solution of alum or Monsel's salt, 
and kept in place by making pressure with the finger or by an interdental 
compress, and allowed to remain for several days. In the event of these 
means proving abortive, resort may be had to the actual cautery. Nor must 
general treatment be overlooked in these cases of obstinate hemorrhage. The 
patient should remain quiet, and constitutional hemostatics should be admin- 
istered, as ergot, turpentine, acetate of lead, opium, and tannic acid. Garret- 
son speaks very favorably of the use of the tincture of erigeron Canadensis, 
given in one-drop doses every minute. In otherwise uncontrollable alveolar 
hemorrhage after extraction of teeth, it might be supposed that trephining 
the jaw, exposing the dental canal, and applying pressure to the inferior 
dental artery-when the bleeding comes from an alveolus of the lower jaw 
-would control the flow; or, in case the trouble wras in the socket of a tooth 
belonging to the upper maxilla, the circulation might be commanded by 
ligating the internal maxillary. If the hemorrhage arose from constitutional 
idiosyncrasy, the danger would probably be increased, as the incisions neces- 
sary to carry into effect either operation would only furnish anothei- surface 
for bleeding. 
Sir Benjamin Brodie, in a case of this kind of hemorrhage, once tied the 
primitive carotid, but without any permanent benefit, the patient finally 
perishing from the loss of blood. 
Fig. 1614. 
Fusion of 
the roots of 
teeth. HARD TUMORS. 
937 
Odontomes and Tooth Tumors. 
There are two general kinds of tumors connected with the teeth, which 
may be designated by the terms hard and soft. 
Enamel Nodules.-Portions of enamel are occasion- 
ally seen out of place, and, instead of being on the 
crown of the tooth, are found attached to the root. 
(Fig. 1615.) They are regarded by Mr. Salter, by 
whom they have been described, as cusps which have 
failed to reach the surface. They are found, on section, 
to consist of a nodule of dentine incrusted with enamel. 
The condition is not likely to give rise to any symptom 
requiring operative treatment. 
Hard Tumors. 
Fig. 1615. 
Hypertrophy.-A tooth may undergo great enlarge- 
ment of its roots, causing absorption of the walls of the 
alveolus in order to accommodate the increase in its bulk. A remarkable 
specimen of the disease, figured in the cut (Fig. 1616), is contained in the 
museum of the Philadelphia Dental College. 
These tumors consist of dentine covered with cementum, the pulp being 
Enamel nodule. 
Fig.1616. 
Fig. 1617. 
Hypertrophy of a tooth with enamel nodule. 
Microscopic section of hypertrophied tooth. 
also greatly enlarged, and sometimes calcified. The microscopic appearances 
in a properly prepared section (Fig. 1617) are characteristic of both bone 
and dentine. Extraction would be the proper remedy in a case of the kind. 
Exostosis is the name employed to express an enlargement of the root of 
a tooth, due to a disorderly outgrowth of the cementum. The effect of such 
Fig. 1618. 
Fig. 1619. 
Bony tumor attached to a molar tooth. 
Section of the same. 
a mass at the bottom of the alveolus, raising the tooth, expanding the walls 
of the socket, and encroaching, as it must, on the dental nerves, is to produce, 938 
SURGICAL DISEASES OF THE MOUTH. 
at first, a general neuralgia of the face, which finally becomes more localized, 
and may be traced to the offending tooth by its extreme 
sensitiveness, and by the pain starting from its root. 
There is another variety of exostosis which is connected 
with the dentine, consisting in an outgrowth from the latter, 
projecting into the pulp-cavity of the tooth, and which gives 
rise to symptoms not unlike those of external exostosis. 
(Figs. 1618, 1619.) A third variety of exostosis was at one 
time supposed to be an outgrowth from the cementum, but, 
from later observations made by Mr. Tomes, would appear 
to originate in the dental pulp. Fig. 1620 is an example of 
such a tumor. The proper remedy is the extraction of the 
tooth. 
Fig. 1620. 
Tumor springing 
from dental pulp.- 
From specimen in the 
museum of the Uni- 
versity of Pennsyl- 
vania. 
Dentigerous Cysts. 
Cysts connected with the teeth are quite frequently met with, and are 
dependent on certain morbid changes which take place about their roots. 
The disease is not limited to either maxilla or to any class of teeth, affecting 
the incisors, cuspids, bicuspids, and molars. The canine and the molars 
appear to suffer more than the other teeth, and in almost all instances the 
permanent rather than the temporary ones. The exceptions 
to this rule are few. Mr. Salter and Mr. Cartwright have 
each seen one case in which the cyst contained a temporary 
tooth. 
The immediate cause of the disease is the presence of some 
local irritant, not always easy of appreciation when the cyst 
is connected with the roots of teeth perfectly developed, but 
doubtless of inflammatory origin, as caries or chronic peri- 
odontitis. In one case of my own, the disease had an ante- 
cedent history of alveolar abscesses, and I have reason to 
believe that the wall of the old abscess became transformed 
into that of the cyst. 
In most instances the irritant is an undeveloped or a dis- 
placed tooth, which, having taken a wrong direction, or become entangled 
with another tooth (Fig. 1621), fails to reach the surface, and creates a dis- 
turbance in the tissues of the 
jaw, resulting in the formation 
of a cyst. (Fig. 1622.) 
According to Mr. Tomes, the 
formation of these cysts does 
not depend on any defect in the 
form of the tooth, but results 
from an accumulation of fluid 
in its encapsulating membrane, 
which, in consequence of erup- 
tion not taking place, remains 
unbroken. 
As the dentigerous cyst in- 
creases in size, the alveolus and 
jaw undergo great changes. If 
the sac is merely connected with 
the root of the tooth, the alve- 
olus becomes gradually absorbed 
as the cyst increases in size, in 
order to make room for its ac- 
commodation. The external en- 
largement of the bone in these 
cases often does not bear any 
proportion to the size of the cavity within. When the disease is due to an 
Fig. 1621. 
Molar having its 
crown between the 
roots of its neighbor. 
-From specimen in 
University. 
Fig. 1622. 
Cyst of the jaw from a displaced tooth, laid open; walls of the 
jaw exposed. DENTIGEROUS CYSTS. 
939 
undeveloped or wandering tooth, the irritation causes a diffused osteitis, 
which may involve a very large portion of the maxilla, producing simul- 
taneous absorption or rarefaction of its interior cancellated tissue, and an 
expansion of the external or compact walls of the bones. (See Figs. 1624, 
1625.) 
Even when the disease appears to be localized, as far as can be known from 
the external manifestations, the rarefying process may be silently at work 
some distance from the apparent seat of the cyst. In the case of a lady 
whom I treated for a dentigerous cyst of the lower jaw, this condition was 
strikingly illustrated. Before I saw her she had had two cysts, appearing at 
intervals, I believe, of about one year,-one near to the angle of the maxilla 
in the position of the wTisdom-tooth, which, from what I could learn, had 
been the cause of the disease; the second was about midway between the 
angle and the anterior dental foramen. These had been operated on, and, 
apparently, with success. The cyst for which she consulted me was between 
the anterior dental foramen and the symphysis of the jaw, and had expanded 
the bone in all directions so as to form a voluminous tumor. The external 
wall was cut away freely, and the case seemed likely to do well. One year 
later the husband of the lady called to consult me with reference to her case. 
She was then residing in the South. The disease was developing again 
towards the angle of the jaw, and manifesting a tendency to repeat itself. 
I advised the extirpation of the right half of the jaw, which was done with 
permanent success. 
When occupying the upper jaw, dentigerous cysts may open into the an- 
trum. Professor Baum saw one case in which both antra were occupied by 
cysts, in one of which was a canine and in the other a molar tooth. 
The interiors of cysts originating from undeveloped permanent teeth are 
rarely single cavities, but are divided into several incomplete and irregular 
chambers by bony septa, and resemble in appearance the frontal sinuses. 
These cavities are occupied by a glairy fluid, sometimes quite transparent, 
occasionally purulent. The subject of dentigerous cysts has received the 
attention of a number of writers, among whom may be mentioned Dupuy- 
tren, Stanley, Paget, Heath, Salter, Fischer, Baum, Tomes, and Jourdain. 
The diagnosis of a dentigerous cyst must necessarily be a matter of some 
difficulty. In a swelling of the jaw suspected to be of this nature, it has 
been suggested to examine the teeth, and if one of the permanent teeth is 
absent, or a temporary one is found occupying the place of a permanent one, 
it will furnish grounds.for believing the tumor to be of this character. Im- 
portance is also attached to the parchment-like crackling which is felt when 
the walls of the cyst become so attenuated as to yield or become flexible 
under pressure. In the two cases which I have seen, this symptom was not 
present. Besides, it is well known that the secondary changes which some- 
times follow the formation of a cyst of this kind render the tumor hard and 
unyielding. The surgeon will be compelled, therefore, to rely, when other 
means fail, on exploratory openings. 
When the cyst is the result of a misplaced or undeveloped tooth, it should 
be opened, whenever possible, through the mouth, dividing the mucous mem- 
brane and the bone, either with a strong cartilage-knife or by the chisel and 
bone forceps, cutting away enough of the wall to expose the cavity of the 
tumor and allow the contents to escape. After this the interior of the cyst 
should be washed out with a solution of permanganate of potash, and after- 
wards mopped with tincture of iodine, stuffed lightly with lint, and its sides 
pressed together in order to diminish the space between them. Suppuration 
will follow, and the cavity finally becomes obliterated by ossifying granu- 
lations. 
Dr. Warren, of Boston, would restrict the operation to simply puncturing 
the cyst, and, after the escape of its contents, forcing the walls together, 
and occasionally injecting through a crevice stimulating liquids in order to 
favor ossification. 940 
SURGICAL DISEASES OF THE MOUTH. 
When the bone has become extensively disorganized, nothing short of its 
removal will effect a radical cure. 
The lower jaw is occasionally the seat of a polycystic disease, which, 
there is every reason to believe, is due to some irritation connected with the 
dental tissues, though no super- 
numerary or bent teeth may be 
found imprisoned in the bone. 
The most remarkable features 
of this affection are the multi- 
locular caverns which are hol- 
lowed out of the maxilla at the 
expense of the cancellated tissue, 
and the extent of bone involved. 
(Fig. 1623.) 
In time a multilocular cyst 
may become, by the more or less 
perfect absorption of the inter- 
mediate septa, a unilocular cyst, 
as in Mr. O'Shaughnessy's* case; 
and the same change seems to 
have been in progress in the case illustrated above. 
The treatment of polycystic disease of the maxilla must be conducted on 
the same principles as that of the more simple forms of the disease, by open- 
ing the cyst and breaking down the partitions, stimulating the interior with 
tincture of iodine, and, after inserting a slight packing, pressing the walls of 
the cavity together. 
When the disease is extensive and refuses to yield to these milder measures, 
it will be necessary to excise the diseased bone. 
Fig. 1623. 
Multilocular cystoma, provoked by a misplaced molar tooth. 
Solid Dentigerous Tumors, or Dentigerous Osteomata.-These tumors, the 
odontomata of Broca, sometimes called warty tumors, are peculiar to the 
lower jaw. They begin primarily in some irritation connected with dental 
development, as in most instances they are found to contain the remains of 
dental tissues. The different structures of the teeth are commingled in a 
disorderly manner, forming numerous nodules or masses, which are thought 
Fig. 1624. 
Dentigerous osteoma. 
to represent many separate tooth-germs which have failed to reach the 
surface. The disease may be so general as to obliterate all traces of a tooth, 
* O'Shaughnessy's Diseases of the Jaw. SOLID DENTIGEROUS TUMORS. 
941 
of which the specimen of Mr. Forget is an excellent example (Figs. 1624, 
1625); or it may involve only a portion of its structure, as shown in Figs. 
1626 and 1627, or in the case of Dr. Goodwillie (Fig. 1626). 
These tumors are uncommon. Heath has been unable to collect more than 
five, namely, one by Ondet, in 1809, one by Fergusson,* one by Forgetf, a 
Fig. 1625. 
Section of the same tumor occupying the place of the two absent molars. 
fourth by Harrison,J and a fifth case reported in Hirden and Wedl's Atlas.§ 
To these may now be added that of Goodwillie, making six cases in all. 
Fig. 1626. 
Localized dentigerous osteoma, removed by operation. 
Treatment.-When the disease, as in Goodwillie's case, is limited, it may 
be cut away with chisel and saw; but when it implicates a considerable part 
* Tomes's Dental Surgery. f Dental Review, 1860. 
J Proceedings of the Odontological Society of Great Britain, December, 1862. 
g Atlas zur Pathologie d. Zahne. 942 
SURGICAL DISEASES OF THE MOUTH. 
of the jaw, as in Forget's case, it will be necessary to remove the maxilla to 
the extent of the tumor. 
There are other tumors of the jaw which are formed by a tooth being 
Fig. 1627. 
Section showing microscopically the chaotic disposition of dental structures. 
turned out of its course and remaining buried in the same portion of the 
alveolus; or it may finally cause the absorption of the bone, and become 
lodged beneath the bone and the mucous membrane, sometimes entering the 
antrum and even the hard palate. 
Errors of this kind can be corrected only by excising the stray tooth. DENTIGEROUS CYSTS. 
943 
No. 
Sex and Age. 
History and Description. 
Duration. 
Teeth inclosed. 
Operation. 
Result. 
Reference. 
1 
F., 17. 
Large cyst expanding into antrum, with 
Months. 
First and second perma- 
Jourdain, Holmes's Surg.. 
great dilatation of body of bone. 
nent right upper molars, 
inverted. 
2d ed., 1875, vol. iv. p. 365. 
2 
3 
M., 60. 
F., 13. 
Cyst size of pigeon's egg, closing the 
nostril. 
Tumor of intermaxillary bone (side not 
stated). 
Many months. 
One year. 
Second upper premolar, 
deeply impacted. 
Monstrous permanent lat- 
eral incisor imbedded in 
intermaxillary, above 
and behind the central 
Jourdain, Holmes's Surg., 
2d ed., 1875, vol. iv. p.365. 
Jourdain. Holmes's Surg., 
2d ed., 1875, vol. iv. p. 365. 
incisor. 
4 
M., young. 
Great swelling in substance of upper jaw; 
first and second permanent molars 
First and second perma- 
nent molars, inverted. 
Free opening; serous contents. 
B. Cooper, Holmes's Surg., 
2d ed.,1875, vol. iv. p. 365. 
never appeared; antrum involved. 
5 
F., 38. 
Each antrum dilated by cyst; purulent 
30 years. 
Right canine: left molar. 
Prof. Baum, Holmes's 
fluid. 
Surg., 2d ed., vol. iv. p. 
366. 
Edwards, Holmes's Surg., 
2d ed., 1875, vol. iv. p. 
366. 
6 
M., young. 
Exostosis from upper jaw, combined with 
bony cyst, containing a temporary 
tooth. 
Second temporary upper 
molar. 
7 
M., 23. 
Cvstic tumor size of English walnut; 
3 years. 
Lower canine; root ad- 
herent to lining mem- 
brane. 
Canine lying in bottom of 
cavity. 
Two-thirds of wall removed ; membrane 
Complete recov- 
Earle, Stanley, Dis. of 
8 
F., 13. 
painless; gradual growth on outside of 
lower jaw. 
Large tumor in cheek; nostril closed; 
palate depressed; nose pressed to oppo- 
vascular and thick; contents glairy. 
Proved a cyst by puncture; freely 
opened into antrum, with which it was 
ery. 
Bones, 1849, p. 269. 
Gensoule, Stanley, Dis. of 
Bones, p. 286. 
site side. 
continuous; serous contents. 
9 
F., young. 
Serous cyst of left upper jaw, size of 
pigeon's egg; teeth this side carious, 
and at times painful. 
Left upper canine, trans- 
verse and very long. 
Distinct from antrum; opened within 
the mouth; compression. 
Recovery. 
Bordenave, Sydenham Soc. 
Trans. (Boston Med. and 
Surg. Jour., N. S., vol. 
10 
F., 31. 
Swelling, pain, and toothache after blow 
4 months. 
Right upper lateral inci- 
Tumor removed entire; contained yellow 
Recovery. 
viii. p. 165). 
Syme,Edinburgh Med.and 
upon nose; tooth removed and not re- 
sorand canine; old roots 
fluid and crown of lateral incisor; 
Surg. Jour., 1838, vol. 1. 
lieved; true nature not known before 
the operation; large tumor. 
Cyst around second lower molar, which 
of temporary set re- 
second cavity with canine behind this 
p. 381. 
11 
F., 16. 
9 months. 
maining. 
Crown of third lower mo- 
lined with crystallized earthy matter. 
Tapped twice, after which serous con- 
Rapid recovery. 
Tomes, Dental Surg., p. 204. 
appeared normal; finally became dis- 
placed and loose. 
lar in a cavity in root of 
lower tooth. 
tents became purulent; tooth ex- 
tracted. 
(Heath, Dis. of Jaw, p. 
372.) 
12 
F., 30. 
Tumor as large as hen's egg. 
10 years. 
Right third molar; root 
inverted and fixed in 
Half of jaw removed. 
Recovery. 
Lisfranc, reported by For- 
get. Heath, Dis. of Jaw, 
coronoid process. 
p. 162. 
13 
M., 56. 
Swelling in lower jaw, opening behind 
front tooth ; serous discharge. 
2 years. 
Canine at bottom; hori- 
zontally. 
Sawed through jaw at two points; piece 
removed. 
Recovery. 
Maisonneuve, op. cit., p. 
164. 
14 
M., 22. 
Tense elastic swelling; had been punc- 
tured within and without cheek pre- 
Third left lower molar im- 
pacted in socket of sec- 
Extracted second molar, which ruptured 
cyst and serum liberated ; its root was 
Complete recov- 
ery. 
Salter, Guy's Hosp. Rep.,3d 
Series, vol. v. p. 326. 
viously ; serum escaped. 
ond. 
greatly absorbed, and third molar ex- 
posed, being impacted in its socket. 
Dentigerous Cysts. 944 
SURGICAL DISEASES OF THE MOUTH. 
No. 
Sex and Age. 
History and Description. 
Duration. 
Teeth inclosed. 
Operation. 
Result. 
Reference. 
15 
F., 18. 
Had normal number of teeth, but left 
central incisor was of temporary set. 
Crown of permanent inci- 
sor projecting into cyst; 
root aborted ; direction 
Both temporary and permanent incisors 
removed. 
Cock and Salter, Guy's 
Hosp. Rep., 3d Series, 
vol. v. p. 325. 
normal. 
16 
17 
M., 40. 
F., 26. 
Cyst size of pigeon's egg; contained thick, 
dark-yellow serum, aud many choles- 
terin plates. 
Dilatation of outer wall of lower jaw; se- 
rous contents. 
2 years. 
Left second bicuspid, im- 
pacted. 
Tooth at bottom of cyst. 
Opened cyst within mouth, and portion 
of its wall removed ; also tooth. 
Recovery. 
Salter, Holmes's Surg.,op. 
cit., p. 366. 
Poland, Guy's Hosp. Rep., 
3d Series, vol. xv. p. 255. 
18 
M., 6. 
Serous cyst on left side, encroaching on 
orbit and mouth, and projecting for- 
ward. 
Right upper canine deficient; cystic tu- 
mor. 
3 years. 
Left upper lateral incisor, 
inverted. 
Opened anterior wall and made window 
in superior maxilla; tooth removed. 
Rapid recovery. 
Bryant, Practice of Surg., 
1872, p. 278. 
19 
F., 17. 
Right upper permanent 
canine. 
Exposed cavity and removed the tooth. 
Recovery. 
Bryant, Practice of Surg., 
1872, p. 278. 
20 
F., 8. 
Nearly solid bony tumor of right upper 
jaw. 
Malplaced tooth growing 
from posterior part of 
orbital plate of bone. 
Entire upper jaw removed. 
Bryant, Practice of Surg., 
1872, p. 279. 
21 
M., 14. 
Expansion of lower jaw as large as Eng- 
lish walnut; thought to be solid. 
5 months. 
Second right lower bicus- 
pid ; root aborted. 
External incision along the bone; saw- 
ing parallel with bone, opened a cyst 
and removed tooth ; lining membrane 
Complete recov- 
ery in 26 days. 
Wormaid, Lancet, 1850, 
vol. i. p. 756. 
thickened and vascular. 
22 
23 
F., 13. 
F., 13. 
Osseous growth of left antrum; contained 
incisor tooth. 
Large, hard tumor of entire left side of 
6 months. 
One of incisor teeth. 
Left lower canine,project- 
Greater part of left superior maxilla re- 
moved; single incision through upper 
lip. 
External incision ; jaw divided at sym- 
Recovery; very 
little deform- 
ity. 
Recovery. 
Fergusson, Med. Times 
and Gaz., Sept. 3,1859, p. 
229. 
Fearn, Brit. Med. Jour., 
24 
M., 10 to 12. 
lower jaw; teeth bad been extracted; 
cystic ; thought to be solid. 
Cyst large as hickory-nut, inclosing sec- 
ond left molar bicuspid ; second tempo- 
rary molar present; considerable pain ; 
purulent discharge in mouth; after- 
wards glairy; a second and smallercyst, 
containing the corresponding right 
tooth, afterwards appeared. 
Cyst in angle of jaw; had opened through 
the cheek, forming a sinus, which 
closed occasionally; supposed to be ne- 
crosis ; fluid purulent. 
ing obliquely from floor 
of cyst. 
Second lower premolars. 
physis, and left half disarticulated; 
fetid pus. 
Second temporary molar removed, and cyst 
widely opened ; roots of the molar pro- 
jecting into it; bicuspid at the bottom ; 
position good; not disturbed ; the sec- 
ond cyst similarly treated. 
Recovery; both 
premolars took 
their place in 
the mouth. 
Aug. 27,1864, p. 241. 
Cheever, Boston Med. and 
Surg. Journ., N. S., vol. 
viii. p. 166. 
25 
F., 70. 
10 years. 
Third lower molar very 
large; one stout quad- 
rangular root. 
Exposed through cheek ; its tooth found 
lying across the cavity and removed. 
Recovery. 
Thorndike, Boston Med. 
and Surg. Journ., N. S., 
vol. viii. p. 166. 
26 
M., 40. 
Very large tumor of right half of lower 
jaw, extending from second premolar 
nearly to tip of articular process: at 
8 to 10 years. 
Second molar oblique and 
nearly underthe first in 
one of the divisions of 
Portion of jaw behind first right premolar 
removed; cyst multiple, bony, but cov- 
ered with many roundish membranous 
Recovery. 
Thorndike, Boston Med. 
and Surg. Jour., N. S., 
vol. viii. p. 166. 
first painless, but afterwards subject to 
the cyst; third cannot 
spots, varying from j/g to % inch in 
very distressing inflamed spells, which 
be found in the net-work 
diameter; there is one larger than the 
lasted a week or two; said to have fol- 
of partitions without 
rest behind the first molar, indicating 
lowed theextractionof atooih; second 
and third molars of this side absent. 
mutilating the prepara- 
tion. 
the place of the missing tooth. 
Dentigerous Cysts.-( Continued. DENTIGEROUS CYSTS. 
945 
27 
M., 17. 
First noticed, when as large as a bean, be- 
2 years. 
Second molar lying in 
Reports two teeth to have been removed 
Recovery in 3 
Thorndike, Boston Med. 
hind lower left first permanent molar; 
outer wall of cyst, at- 
from this side one year ago, " which 
weeks so as to 
and Surg. Jour., N. S., 
since has gradually grown, until now 
tached by its side, up- 
were succeeded by others;" jaw sawn 
chew meat; de- 
vol. viii. p. 166. 
it reaches from articular process toca- 
right, perfect, but far 
through socket of left lateral incisor, 
formity very 
nine; greatest enlargement external; 
from its proper place; 
and left half disarticulated; walls of 
cyst are bony, except a large membra- 
slight. 
hard; no pain; second and third mo- 
third in angle of jaw, 
lars of this side absent; also second 
facing the cyst; not 
nous spot behind first molar, where the 
premolar (probably pulled); other teeth 
prominent; has no fang. 
second and third should have ap- 
normal; principal complaint, of defor- 
mity and impaired motion of jaw; 
peared. 
fluid serous. 
McCoy, of Sierra Leone, 
28 
M., 14 (ne- 
gro). 
Left upper canine wanting; tumor ex- 
years. 
Left upper permanent ca- 
Punctured, and glairy fluid escaped; 
Recovery. 
tended into antrum; painless. 
nine firmly imbedded 
single straight incision through upper 
West Africa, Lancet, 
and growing from nasal 
lip into nostril; exposed cyst and ex- 
Aug. 19,1871, p. 259. 
process of superior max- 
cised anterior wall with saw and for- 
ilia. 
ceps; cavity contained thick, gelati- 
nous substance, and canine tooth pro- 
jecting from above; was sound and 
fully developed. 
Stocks, Brit. Med. Jour., 
29 
F., 18. 
Cystic tumor, right upper jaw; tempo- 
3 years. 
Right upper permanent 
No external incision; punctured with 
Recovery. 
rary tooth had been extracted. 
canine tooth, with fang 
surrounded by bone. 
gouge; opening enlarged with forceps; 
contained serum. 
July 10, 1875, p. 43. 
Jackson, Brit. Med. Jour., 
30 
M., 4. 
Very hard tumor of left upper jaw; no 
pain; slow. 
" Misplaced tooth." 
Triangular section of upper jaw from in- 
side of mouth, using bone forceps. 
Recovery. 
Oct. 6, 1877, p. 479. 
31 
M., 34. 
Large bard tumor of lower jaw, with a 
9 years. 
Right lower bicuspid, with 
Punctured cyst; was hollow; in two 
Recovery. 
Heath. Lancet, Dec. 21, 
yielding part. 
perfect crowm and two 
small fangs. 
weeks crushed cyst-walls; it extended 
between the two tables of bone; inner 
table of jaw and teeth unimpaired; no 
tooth felt; pieces of bone separated 
by suppuration, and one month later 
tooth found at bottom of cavity. 
1879, p. 877. 
History, Description, etc. 
32 
Capsule of bone as large as an English chestnut, probably having been filled with serum, rising from floor of antrum, and standing out free in its cavity; one loose 
Cartwright, Guy's Hosp. 
supernumerary tooth within; no external deformity 
; no history. 
Rep., vol. v. p. 328, 3J 
Series (Salter). 
33 
Portion of lower jaw, which had been removed, containing a canine tooth, lying horizontally in floor of a large cavity in the bone; no further history. 
Tomes, op. cit., p. 191. 
(Heath, op. cit.) 
34 
An osseous cyst in palate process of left upper maxilla, separating its compact laminae, caused by an inverted canine, which had curved upon itself, and now pro- 
Holmes's Surg., and Bos- 
jects into the cavity, with its root pointed out to the alveolar process ; cavity thrice the volume of the tooth. 
ton Med. and Surg. 
Journ., op. cit. 
35 
Dr. Forget gives a case of a woman about 30, with a hemispherical tumor of right side of lower jaw, 
upon whom Nelaton operated, exposing tumor; made a hole 
Nelaton, Heath, op. cit., p. 
in the outer wall, ard found a tooth projecting into the cyst, undoubtedly a molar; the tooth was removed, followed by perfect recovery. 
166. 
36 
Bottini reports a case, in a woman aged 23, of subperiosteal and subcapsular disarticulation of left side of lower jaw, for what proved to be a dentigerous cyst in 
Bottini, Heath, op. cit., p. 
connection with the wisdom-tooth. 
164. 
vol. ii.-60 946 
SURGICAL DISEASES OF THE MOUTH. 
It will be seen from an analysis of the preceding table that the teeth most 
commonly found displaced are the molars, 14 of the 36 belonging to this class ; 
next in frequency are the canine, 12 in number; next the incisors, 5 in number; 
and last the bicuspids, 3 in number. Eighteen of the patients were females, 
15 males, and in 3 the sex is not stated. The youngest was four years, and 
the eldest seventy years old. The result of operation is given in 22 instances, 
in all of which recovery followed. 
DISEASES AND INJURIES OF THE JAWS. 
The upper and lower maxillae are very unlike, in their anatomical structure, 
their relations, and their functions. The upper jaw, in addition to bearing its 
part in the work of mastication in common with the lower jaw, contributes 
to the formation of the orbits, the nasal cavity, the mouth, the palate, and 
the tear-duct, besides containing a large cavity for the maxillary sinus or 
antrum. The lower jaw is chiefly concerned in mastication. In consequence 
of these functional differences, the diseases of the maxillae, as well as their 
liability to morbid processes, are very unlike, the upper jaw suffering much 
more frequently than the lower. 
Deformities.-Most of the deformities of the lower jaw are acquired, and 
are either produced by pathological causes or result from some vicious habit. 
Among the former, the cicatricial contraction which follows burns or scalds 
is the most common. In the young, the power of inodular tissue in producing 
this kind of distortion is very marked. When the cicatrix is situated beneath 
the chin, the anterior part of the jaw becomes gradually bent downward, and 
when it is disposed obliquely from the chin to the side of the neck, in time 
a noticeable change in the direction of the symphysis menti takes place. 
Tumors occupying the parotid region, when they attain a large size, not 
only change the direction of the jaw, but even alter the shape of its ramus. 
In extreme cases of hypertrophy of the tongue, the weight of the organ 
hanging from the mouth will cause both elongation and bending of the 
anterior portion of the jaw. Irregularities of the teeth, by bringing in 
apposition only limited portions of the dental arches, will also change the 
direction of the jaw, so as to alter the expression of the face. 
The treatment necessary to remedy these deformities consists in removing, 
as far as possible, the determining cause: therefore plastic operations are 
indicated in cases of burns, extirpations for tumors, amputation of the re- 
dundant part of the tongue in hypertrophy, and correction of the vicious 
teeth in cases of dental irregularities, either by mechanical means or by 
extraction. 
The influence of certain habits of childhood, as sucking the thumb, on the 
shape of the lower jaw, causing deformity of the bone, has been particularly 
noticed by Mr. Vasey.* I have not seen among American children-with 
whom the practice is by no means uncommon-anything answering to the 
deformities described by Mr. Vasey and by Dr. Ballard, the latter of whom 
has had his attention attracted to the kindred habit of tongue-sucking. 
There is a congenital deformity of the inferior jaw which consists in a 
departure from the proper angle between the ramus and the body of the 
bone, which, becoming too obtuse, produces an unnatural elongation of the 
chin, in some respects not unlike that peculiar to the aged jaw. 
The use of an occipito-mental bandage, and the acquirement of the habit 
of supporting the chin on the hand when sitting, will contribute to the cor- 
rection oj' the deformity. 
Diseases of the Lower Jaw. 
Anchylosis of the Jaw.-Though the term anchylosis is usually employed 
to express rigidity or stiffness incident to changes connected with the articu- 
* Transactions of the London Pathological Society, vol. xxvii. DISEASES OF THE LOWER JAW. 
947 
lations, I shall use it here in a broader and more general sense, as express- 
ive of all closures of the jaws, whether from reflex or pathological causes. 
Reflex anchylosis.-Among the reflex or spasmodic causes is the irritation 
attending the eruption of wisdom-teeth, which acts through the connections 
between the sensory and motor branches of the fifth pair of nerves, exciting 
spasm or rigidity in the masseter, pterygoid, and temporal muscles. I have 
seen patients suffer from this cause for two weeks, unable to open the mouth 
more than was necessary to admit liquids. Cases of this kind can only be 
relieved by administering ether and extracting either the offending tooth or 
a molar to give it room. 
Mumps will sometimes provoke a similar though less pronounced rigidity 
of the jaw, as the latter cannot be depressed without pressing against the 
swollen and tender glands. The stiffness disappears with the subsidence of 
the disease, for which time only is required. A like condition may follow the 
presence of a tumor in the parotid region. Acute tonsillitis will also excite 
reflex spasm of the muscles of mastication, for the relief of which the prac- 
titioner must rely on antiphlogistic remedies addressed to the affected glands. 
Irritation of the upper spinal nerves from injury to the vertebrae consti- 
tutes another source of reflex spasm of the jaw. The following case is in 
point: 
A machinist consulted me on account of spasmodic contraction of the 
muscles of mastication, rendering him unable to separate the jaws except 
for a short distance. This condition, which had existed for several months, 
came on gradually after a fall which he received by the upsetting of his 
wagon, in which he struck on the side of his head and neck. The neck 
was also stiff, and great soreness was complained of when pressure was made 
along the sides of the cervical vertebrae, or when an attempt was made to 
turn the head, which wras always accompanied by a like movement of the 
body. 
Under reflex anchylosis also come tetanus and trismus. I have known the 
latter to follow the extraction of a tooth in a patient of a highly irritable 
nervous organization. This condition yields to a warm bath and opiates. 
Pathological anchylosis.-In this form of rigidity or immobility there has 
been some alteration of structure, either in the tissues of the mouth and the 
cheek, or in the components of the temporo-maxillary articulation. The 
worst cases of anchylosis from the former cause which I have ever wit- 
nessed were those which had been produced by the reckless use of mercury. 
Excessive ptyalism was often followed by extensive sloughing of the gums, 
cheeks, muscles, and even, to some extent, of the maxillae, leaving, instead, 
a dense cicatricial tissue, which, contracting with age, entailed a rigid and 
immovable state of the jaw, seriously interfering with both mastication and 
articulation. The condition is rendered still more distressing when the 
cheek has been destroyed, leaving the teeth and jaws exposed, and allowing 
the saliva to dribble constantly over the face and neck. 
Rheumatoid arthritis of the temporo-maxillary articulation will cause an- 
chylosis by the fibrous and bony deposits which occur in and around the 
joints. Most of these cases of osseous bridges which pass between the upper 
and lower maxillae, and which resist all movement of the jaw, are attribu- 
table to this disease. Inflammatory attacks, both traumatic and idiopathic, 
of one of the masseter muscles or of the articulation, constitute another 
source of stiffness or immobility of the jaw. 
Finally, abscesses under the temporal fascia or fractures of the zygomatic 
arch with depression, by provoking irritation and inflammation of the tem- 
poral muscle, will induce a similar condition. 
Treatment.-After no small experience in the treatment of anchylosis 
from pathological causes, I feel compelled to state that the results in my 
hands have been exceedingly unsatisfactory; and, so far as I have been able 
to observe, no better results have been obtained by other surgeons. Where 
the case is one in which the soft parts have been destroyed by sloughing, it 948 
SURGICAL DISEASES OF THE MOUTH. 
is possible, by dissecting away the cicatricial tissue and prizing the jaws 
apart, to obtain some temporary relief by improving the mobility. But this 
is of such short duration that, unless the inodular tissue can be replaced with 
sound mucous membrane or with skin,-which is rarely possible,-it is useless 
to subject the patient to an operation of such severity, as the reformation 
of the intractable material is certain to take place, and to increase rather 
than lessen the immobility. Occasionally, when the commissure of the 
mouth is gone, or the side of the cheek partially lost, the defect may be 
remedied by a plastic operation, or, in very slight cases, by dissecting up the 
remnants of the cheeks from the jaws, and, after freshening their edges, 
bringing them together with interrupted or twisted sutures, when union 
may be obtained. 
By the aid of an intelligent dentist it is sometimes possible to obviate the 
inconvenience resulting from the opening in the side of the cheek by con- 
structing a rubber or metal drain or obturator for closing the gap. 
An operation devised by Esmarch will, in some of the severer cases of 
anchylosis following sloughing, not only increase the space between the jaws, 
but restore considerable movement. This consists in cutting out a wedge- 
shaped piece from the maxilla, in advance of the cicatricial tissue, and estab- 
lishing an artificial joint. This can be done by making a small opening in 
the soft parts along the base of the jaw, and, after exposing the latter, excising 
from a quarter to half an inch of the bone, either with the Hey or a chain saw. 
Simple division of the maxilla, as practiced by Rizzoli, with strong cutting 
pliers on the inside, has this disadvantage,-that it cannot always prevent 
the reunion of the bone. Cutting through the bone and securing a false 
joint is equally well adapted to cases of immobility resulting from bony 
consolidation of the joint, in which, if the muscles are sound, the section 
should be made through the ramus, in order to obtain the power of the 
masseter and internal pterygoid. 
When the difficulties are such as result from inflammatory lymph about 
the temporo-maxillary joint, the 
resistance must be overcome 
by insinuating between the 
teeth a divulsor (Fig. 1628), 
which will serve to separate 
the jaws when the handles of 
the instrument are forced to- 
gether. The blades of the 
divulsor must be carefully cov- 
ered either with rubber or with 
leather, in order not to injure 
the teeth. 
Wedges of wood are some- 
times used to force the jaws 
asunder, but are inferior in value 
to the divulsor. When the 
rigidity depends on the presence of lymph between the muscular fasciculi of 
the masseter, much may be done to favor the absorption of the new forma- 
tion and restore the action of the muscle by 11 massage," accompanied with 
the daily use of the dilator. 
Fig. 1628. 
Divulsors or lever forceps. 
Periostitis of the maxilla occurs from both local and constitutional causes. 
Among the former, caries or some other disease of the teeth, and the vapor 
of phosphorus, constitute the most prolific sources of the inflammation. The 
constitutional conditions which excite periostitis are syphilis, mercurial poison- 
ing, rheumatism, certain exanthematous fevers, and struma. The symptoms 
are pain in the bone, sensitiveness of its surface to pressure, and an elevation 
of the periosteum, accompanied, in acute cases, with swelling of the face and 
more or less fever, with general disturbance of the system. When it has a DISEASES OF THE LOWER JAW. 
949 
syphilitic origin, the disease is very insidious, and may make considerable 
progress before being detected, leaving permanent thickenings or nodes. 
The treatment of periostitis of the jaws will depend upon the exciting- 
cause. In acute cases (arising from cold, or from rheumatism), and when 
there is general soreness of the jaws, and perhaps of the entire body, with 
dull aching of all the teeth, an active purge, followed by small and frequently- 
repeated doses of the iodide of potassium and the nitrate of potash in solution, 
steaming the face with the vapor of hot water, and, occasionally, a dose of 
Dover's powder, will secure the resolution of the disease. If there are diseased 
teeth, they should be removed. It is possible that in searching for such no 
decay may be detected ; but if there is a tooth which on being pressed upon, 
oi- smartly tapped with the handle of a pocket-knife or a key, is found to be 
sore, its removal must be insisted upon, though there are no external marks 
of disease. The connection between the periosteum and the endosteum of 
the maxilla must not be forgotten, as inflammation of one, if neglected, may 
terminate by involving the other. 
I do not doubt that in some of the cases of maxillary periostitis which 
have fallen under my notice, and which arose from disease of the teeth, the 
latter disease was secondary to an inflammatory condition of the alveolar 
periosteum or the endosteum, or of both together. 
Periostitis depending on constitutional conditions, as syphilis or struma, 
will demand general treatment. When arising from the first-named disease, 
iodide of potassium, with or without a small amount of bichloride of mer- 
cury, will be indicated, provided the constitution has not been seriously 
damaged by the ravages of the old disease. If this proves to be the case, 
it will be best to omit mercury in any form, and rely on a judicious alter- 
nation of alteratives and tonics, as iodide of potassium, nitro-muriatic acid, 
and iodide of iron and cod-liver oil. 
In strumous periostitis, the use of the last two articles named, with decoc- 
tions of sarsaparilla and chimaphila umbellata, together with a diet rich in 
all the plastic elements of nutrition, and proper hygienic surroundings, will 
constitute our chief reliance. 
Sequels.-Periostitis is liable to terminate in osteitis, abscess, or necrosis. 
Osteitis of the maxilla is attended with a gnawing or boring, deep-seated 
pain in the jaw, with periodical exacerbations of suffering, particularly in 
the evening or at night, with swelling, also, of the overlying soft parts. 
The lower jaw is most prone to be attacked. The bone, in consequence of 
the plastic transudation, becomes expanded or swollen ; the teeth generally 
ache and are tender. The enlargement of the jaw may be limited to a small 
portion of its structure around one of the alveoli if the disease commenced 
at the root of a tooth. Or it may be diffused, spreading through the prin- 
cipal part of the bone, and unless speedily checked will end in caries, sup- 
puration, or necrosis. 
Treatment.-In every case of osteitis the jaw must be carefully examined 
for any diseased teeth, the removal of which, if found, should take prece- 
dence of every other measure. If, after getting rid of this source of irritation, 
the disease does not spontaneously subside, and if the morbid action is not 
referable to a constitutional vice, an antiphlogistic course must be adopted. 
If the disease ends in caries, there will be one or more fistulous openings, 
indicated by a little bit of granulation tissue, through which a purulent or 
watery discharge issues. Under these circumstances, if a probe is introduced 
into the sinus, the bone will be found honeycombed. When the caries is 
circumscribed, the molecular ejection of the dead particles of bone may be 
effected by means of the " liqueur de Villate" or the tincture of iodine; but 
when extensive, it cannot be left to natural processes, and must be scooped 
out with a delicate chisel-shaped scraper, at the same time washing out the 
detritus until the sound bone has been reached. 
The known chemical action of certain mineral acids, as the sulphuric, on 950 
SURGICAL DISEASES OF THE MOUTH. 
the bone-salts, has rendered this agent quite popular as a remedy in caries. 
When employed for this purpose, the ordinary aromatic sulphuric acid 
applied daily with a glass brush dissolves away the devitalized osseous frag- 
ments and stimulates healthy granulations. 
When the expansion of the bone is not promptly arrested, an opening 
should be made into its structure with the crown of a delicate trephine, on 
the same principle that incisions are adopted in cases of phlegmonous ery- 
sipelas in order to prevent sloughing of the cellular tissue. 
Chronic osteitis, depending, as it generally does, on syphilis, will require 
antisyphilitic remedies. 
Abscess.-Suppuration of the jaw may be, as has been stated, one of the 
sequels of periostitis, yet osteitis and endostitis are intermediate links in tbe 
chain of causation, provoked either by an alve- 
olar abscess oi' by the presence of diseased teeth, 
cysts, and other tumors of the jaw. These ab- 
scesses are single and multiple, or perhaps it 
would be more accurate to say circumscribed 
and diffused. (Fig. 1629.) The latter may so 
thoroughly disorganize the maxilla as to render 
all attempts at preservation useless. 
Symptoms.-It is no easy matter to diagnose 
an abscess of the jaw. There will have been a 
previous inflammatory history, with deep-seated 
pain, expansion of the walls of the bone, and 
possibly one or more rigors,-phenomena which 
indicate the occurrence of suppuration; the 
same signs, however, accompany other affections 
of the jaw, as the severer forms of alveolar 
abscess and endostitis. As the recognition of the 
true condition is of vital moment in connection 
with treatment, it will be a wise expedient, in 
case of doubt, to make an exploratory puncture 
with a drill or the small crown of a trephine, 
which, even in the event of no abscess being 
found, can do no harm. When the suppuration 
finds its way to the surface of the bone, forming 
sinuses, as is sometimes the case, tbe nature 
of the disease is self-evident. 
Treatment.-Abscess, unless it happens to open into the socket of a tooth, 
can be relieved only by surgical measures; and, as in other tissues, an open- 
ing should be made by the trephine or cbistl, and the purulent accumulation 
evacuated, after which the cavity should be washed, and healthy granula- 
tions encouraged by treating the interior of the cavity with dilute tincture 
of iodine. In all these cases of osteitis or abscess, the general health of the 
patient must be improved by tonics and a liberal diet. 
Fig. 1629. 
Circumscribed abscess of the lower jaw. 
Necrosis.-Though neither jaw is exempt from necrosis, the disease mani- 
fests a preference for the lower maxilla. This may possibly be due to the 
combined agency of great functional activity, the abundance of compact 
tissue in its structure, and its almost entire dependence on a single artery for 
its blood-supply,-physiological and anatomical peculiarities which do not 
characterize the upper jaw, which in mastication is passive, possesses little 
compact tissue, and receives its blood from several different sources. 
The immediate causes of necrosis are periostitis and osteitis. In periostitis, 
the vital or vascular connection between the membrane and the bone is 
endangered in consequence of the inflammatory infiltration ; and when this 
connection is destroyed, the death of the bone, to some extent, must follow, 
either partially or in its totality, affecting the alveolus alone or the bone. It NECROSIS OF THE JAW. 
951 
is true that the life of the maxilla is not wholly dependent on the vessels of 
the periosteum. The dental branches of the internal maxillary arteries con- 
tribute also to the nutrition of the bone, but this is a secondary office as 
compared with the supply of the teeth ; and hence, when the work of sub- 
stituting the periosteal function devolves upon these vessels, the life of the 
bone becomes endangered ; and when an osteitis is developed, w'hich is often 
associated with a periostitis, the danger of necrosis is increased in a twofold 
degree. 
The exciting causes of necrosis are traumatism, disease of the teeth, poi- 
sons generated in the human body, as in certain exanthemata, scarlatina, 
variola, and, in one case mentioned by Bryant, in rubeola, also syphilis, the 
action of mercury, and the fumes of phosphorus. 
Alveolar necrosis, when produced by traumatic causes, as the fracturing 
of the socket in extracting a tooth, requires no active interference. Exfolia- 
tion of the sequestrum will, in time, follow without any particular inconve- 
nience being experienced by the patient. When the necrosis occurs at that 
period of life when the jaw is occupied by the temporary teeth, interference 
is still less desirable; for, as stated by Mr. Tomes, any premature attempts 
to drag away the sequestrum may be attended with the loss of the germs of 
the permanent teeth. It should be allowed to remain until, separated both 
from the bone and from the tissues of the gum, it can be picked away with- 
out force. 
Exanthematous necrosis is that form of the disease which attacks the al- 
veolus of the jaw as a sequel of scarlet fever or of some other exanthema. 
This variety of necrosis was first described by Mr. Salter.* It begins with 
redness and tenderness of the gums, which soon shrink away from the alve- 
olus lining the necks of the teeth and the bone, leaving the latter exposed. 
It is accompanied by the peculiar odor which belongs to dead bone about 
the teeth. The disease generally affects both sides, and sometimes corre- 
sponding portions of each. The temporary teeth drop out, and subsequently 
the germs of the permanent ones, with the sequestrum of the alveolus down 
to the body of the bone. As the loss of the teeth within the limits of the 
necrosis is permanent, there necessarily follows deformity varying with the 
part of the jaw involved, being, of course, less in the regions of the molars 
than in those more anterior. 
The treatment consists in keeping the mouth free from the offensive dis- 
charges, and arresting the fetor by frequent washings of weak solutions of 
persulphate of iron, permanganate of potash, or bromo-chloralum, until the 
sequestra loosen and can be removed, after which the patient quickly 
recovers. Tonics, especially iron, with good food, will also be indicated. 
Phosphor-necrosis is a comparatively recent form of maxillary necrosis, and 
owes its existence to a modern manufacturing industry,-the making of 
lucifer-matches. The first public notice of the disease appeared in Germany, 
by Lorinser, who had witnessed the necrosis as early as 1839, in an oper- 
ative employed in a match-factory at Vienna. In Great Britain, the first 
writer who treated of the disease was Dr. Wilks,f in 1846. Since that time 
phosphor-necrosis has been noticed by several German writers, particularly 
by Von Bibra and Geist,J whose field of observation was the Nuremberg 
manufactory of lucifer-matches; and in England, by Salter§ and Bristowe.|| 
In this country the malady was first described by Dr. James R. of 
New York, in 1856. This form of necrosis occurs among operatives engaged 
in the manufacture of lucifer-matches. Only in a few instances has the 
disease been contracted in any other way. Mr. Paget** mentions one case 
* Guy's Hospital Reports, vol. iv., 3d Series. 
f Guy's Hospital Reports, 1846. 
j Die Krankheiten der Arbeiter in den Phosphor- und Holzfabriken. 
ijt Holmes's Surgery. 
|| Report to Privy Council, London, 1863. 
New York Journal of Medicine, May, 1856. 
ss Medical Journal and Gazette, vol. i. p. 157, February 5, 1862. 952 
SURGICAL DISEASES OF THE MOUTH. 
in which the necrosis was the result of exposure to the influence of phos- 
phorus in the preparation of certain compounds of which this substance 
constituted a part. 
A child came under my own notice who was suffering from the early symp- 
toms of the disease, in consequence of chewing the contents of a match-box 
which it had got possession of during the absence of its parents. The little 
patient passed out of my observation, and of the final result I cannot speak 
with certainty. 
With regard to the manner in which the poison of phosphorus operates 
there is some difference of opinion. A few writers, among them Lorinser 
and Langenbeck, believe that the disease is only an expression of general 
blood-poisoning ; but the weight of authority is, with good reason, on the side 
of its local origin, in confirmation of which no stronger argument can be ad- 
duced than the fact that the disease is never seen except in operatives the 
cavities of whose teeth are exposed by caries. Until this occurs, such per- 
sons may labor with impunity, exposed to the deleterious agent. Phosphorus 
produces its effects, most likely, in the form of either phosphorous or 
phosphoric acid, its fumes meeting in the air or the mouth the necessary 
amount of oxygen to form these acids, which, by entering the tooth-cavity, 
reach the alveolar periosteum, either at the bottom of the socket or on its 
side. 
Both jaws are liable to be attacked, but the lower one suffers oftener than 
the upper. In an analysis of 111 cases, I find that the necrosis was located 
in the inferior jaw 58 times, in the superior jaw 41 times, and in both upper 
and lower maxillae 12 times. 
Symptoms.-The earliest symptom of phosphor-necrosis is a paroxysmal 
dull pain experienced in some portion of the alveolus occupied by an un- 
sound tooth, and is generally regarded as simply a toothache. The teeth 
are also sore to pressure. After a time an eruption appears on the gums; 
they become soft, tender, swollen, spongy, and of a purple or leaden hue. 
The pain, which at first was intermittent or irregular, becomes more con- 
stant. The mucous membrane on the inside of the mouth adjacent to the 
disease assumes very much the same appearance as that presented by the 
affected gums; the swelling involves the face, the eyelids, and even the scalp ; 
it extends to that part of the neck below the jaw, greatly altering the general 
appearance and expression of the countenance. When suppuration com- 
Fig. 1630. 
Phosphor-necrosed jaw. 
mences, the pus escapes around the necks of the teeth, which become loose 
and drop out; this unhealthy pus, emitting, with the other secretions of the 
mouth, a fetid odor, burrows along the bone, separating the periosteum, and 
forming long, fistulous tracks. These open at different points, laying bare NECROSIS OF THE JAW. 
953 
the bone, which generally presents a dull gray or dark appearance and an 
irregular, worm-eaten surface. (Fig. 1630.) Coincident with these changes, 
a large fibrinous and corpuscular transudation takes place about the under 
portion of the bone, assuming the lower jaw to be the diseased one, which 
plays a most important role in the subsequent history of the case. The gen- 
eral system seldom remains undisturbed during the progress of the necrosis. 
The extensive suppuration and the contaminating discharges which are con- 
stantly poured into the mouth, together with the severe pain which is expe- 
rienced, may induce rigors, followed by an irritative fever, nausea, vomiting, 
diarrhoea, and profuse sweatings, the patient finally dying from exhaustion 
or pyaemia. 
Pathology.-The first morbid impression in a case of phospbor-necrosis 
would appear to be made by the acid upon the periosteal lining of the alve- 
olus. From thence it is most natural to suppose that the inflammation is 
propagated along two lines of tissue-continuity,-that of the cancellated 
tissue of the bone and that of the periosteal layer of the jaw,-so that, 
being attacked on all sides, the body of the jaw must necessarily die in its 
totality. The disease, in the case of the lower maxilla, is usually limited to 
the body of the bone, leaving the rami undisturbed; though there are excep- 
tional cases in which the latter have participated in the general destruction, 
leaving only the condyles, and in a few instances even these have been 
involved. 
Repair.-I have already alluded to the accumulation of a large transuda- 
tion in front and behind the base of the lower jaw, which is actively going 
on during the progress of the disease. This not only forms an embankment 
which protects the parts below from the intrusion of pus, after the same 
manner as does the wall of an abscess, but constitutes, in addition, the mould 
for reforming the destroyed jaw. 
This salutary process may be defeated, but there are a number of cases 
in which, after the necrosed piece has been extracted, a well-formed rim of 
bone remained, which had been constructed pari passu with the separation 
of the sequestrum, and which, though unarmed by teeth, continued to 
discharge the functions of the lower jaw. Such were the cases reported 
by Billroth, Geist, Perry,* Smith,f Hunt,£ and Morton ;§ and in instances 
given by Geist, even when the entire jaw with its condyles has been de- 
stroyed and ejected, there has followed a like extensive restoration of the 
bone with very good motion. The durability of the new substitute, how- 
ever, is not always assured. In some cases at least it has diminished in size 
under use,-indeed, almost entirely disappeared ; and the possibility of such 
an occurrence gives considerable practical force to the suggestion of Mr. 
Salter, of providing the supplemental jaw as soon as possible with artificial 
teeth. 
Treatment.-The adoption of such measures as will protect the operative 
against the dangers of phosphorus-poisoning is a duty imperative on every 
manufacturer of lucifer-matches. It is one of the compensations of indus- 
trial life, that, while certain necessary occupations are attended with great 
personal danger, science has provided the means by which the risk may be 
greatly diminished or entirely obviated. The collier, with the charm on 
his head, plies in safety his pick in coal-shafts, surrounded by an explosive 
gas; and the worker in many of the materials employed in the construction 
of tapestries and various upholsteries escapes, by the use of carbolic acid, 
the dangers of carbuncles. A like immunity will be attained if those engaged 
in carrying on the manufacture of matches will carefully exclude all oper- 
atives who are the subjects of dental caries or who neglect to have decayed 
teeth carefully plugged; they should also provide alkaline respirators to be 
«■ Medico-Chirurgical Transactions, vol. xxi. p. 290, 1838. 
f St. Bartholomew's Hospital Reports, vol. i. p. 101, 1865. 
J American Journal of the Medical Sciences, vol. xlix. p. 353. 
£ Surgery, Pennsylvania Hospital, p. 216. 954 
SURGICAL DISEASES OF THE MOUTH. 
worn by the workmen exposed to the phosphorous fumes. The respirator 
recommended by Mr. Graham consists of equal parts of unslacked lime and 
sulphate of soda, quilted in between two layers of some fabric sufficiently 
porous to admit of the passage of air, which can be worn over the mouth 
when at work. 
In treating a case of phosphor-necrosis, the course of the medical attendant 
must be regulated by the stage of the disease. 
During the early or what may be considered the acute period of the dis- 
ease, free incisions should be made through the gum down to the bone: by 
thus opening two or more avenues for the escape of inflammatory products 
the necrosis may be limited, for it can scarcely be doubted that a part of the 
destruction of the jaw is the result of purulent burrowing. When this 
period has passed, the treatment must be an expectant one. In order to de- 
fend the system against the poisonous action of the fetid discharges which 
are poured into the mouth, the latter must be frequently washed out with 
solutions of permanganate of potash containing a little tincture of myrrh, 
or with dilute alcohol. The strength of the patient is to be sustained by 
nutritious liquid nourishment, rest and relief from pain are obtained by the 
use of anodynes, and any point of bone which may protrude in a way to irri- 
tate adjacent parts can be nipped off with a pair of cutting pliers; but no 
attempts to remove the sequestrum will be proper until it has been thoroughly 
loosened and detached by natural processes, when it should be seized with a 
pair of bone forceps and extracted through the mouth. When both halves 
of the inferior maxilla are involved in the disease, the operation will be facil- 
itated by dividing the bone at its symphysis and removing each half sepa- 
rately, and when the condyles remain unaffected, they must be separated 
from the rami by means of the cutting pliers. In case the disease is seated 
in the upper jaw, some modification of the rule as to early surgical pro- 
cedures may be made, not with reference to the propriety of primary incisions 
in order to limit the extension of the necrosis, which are as judicious here 
as when the lower jaw is implicated, but with regard to the extraction of 
the sequestrum, which may be undertaken at an earlier period than would 
be proper in the inferior maxilla, on account of the nasal, orbital, or othei* 
relations of the bone, as well as of its exceptional disconnection with the 
muscles. 
Syphilitic necrosis.-The bones are peculiarly liable to become affected by 
the syphilitic poison, and among the different pieces of the skeleton the max- 
illae frequently suffer. When the upper jaw is attacked, the palatine plates 
are usually first affected. Commencing as a periostitis, the disease separates 
the soft tissues from the horizontal plates by the inflammatory formations, 
until, deprived of blood, the bones perish ; or the destructive process may 
extend to the alveolus. I have removed the entire palatine plate, and 
the greater part of the alveolus of both maxillae, on account of syphilitic 
disease. 
The diagnosis of syphilitic necrosis is easily established. It is among the 
later manifestations of the disease, and, in addition to the antecedent history, 
there will always be external signs to attest the syphilitic paternity of the 
necrosis. 
Treatment.-If the disease is detected during the early stage of the peri- 
ostitis, the bone maybe saved by active antidotal measures, especially by 
the bold administration of the iodide of potassium; but after the necrosis has 
been once established, nothing can be done to get rid of the sequestrum until 
it has become well detached from the surrounding healthy bone, when its 
extraction will be indicated. 
Mercurial necrosis.- Fortunately, this variety of necrosis is seldom witnessed 
at present. It is usually accompanied by extensive sloughing of the mucous 
membrane of the mouth and the tissues of the cheek, occasioning great de- 
formity and disability from the resulting cicatricial tissue. (See Anchylosis of 
the Jaw.) TUMORS OF THE LOWER JAW. 
955 
The rule for dealing with the sequestrum in phosphor-nccrosis applies with 
equal force to necrosis of the jaw from other causes. 
Tumors of the Lower Jaw. 
Different kinds of tumors are met with in both the upper and the lower 
jaw. They may be classified as follows: cystic, osseous, fibrous, cartilaginous, 
angeiomatous, sarcomatous, myxomatous, and carcinomatous. 
Cystic Tumors are generally associated with some disease of the teeth, or 
some error in dentition, and have been already considered under the head of 
dentigerous cysts. 
Occasionally, however, tumors of this nature, both congenital and acquired, 
have been observed in which the disease could not be traced to the above 
causes, and which must, therefore, have originated in the endosteum, or in the 
cancellated tissue of the bone. The characteristic feature of these cysts is a 
great expansion of the external walls of the jaw, the latter being thinned out 
to such a degree as to render them pliant and crackling under pressure. The 
internal appearances of the growths do not materially differ from those 
presented in well-marked cases of dentigerous cysts, and the same principles 
will hold in the treatment of both affections. 
Fibromata.-A considerable proportion of all the morbid growths of the 
lower jaw belong to this class. They may arise from the periosteum or from 
the interior of the bone. Their growth is usually tardy, their prevailing form 
spherical, their surface smooth, and their consistence firm. When spring- 
ing from the periosteum, the principal projection of the tumor is external; 
but when beginning in the central portion of the jaw, it will encroach 
on the cavity of the mouth, as well as enlarge in the outward direction. 
Even when growing from the periosteum, the underlying compact wall of 
bone is often absorbed, so that the growth will form for itself a bed in the 
cancellated tissue, causing its absorption. 
Recurring fibromata are not common in the lower jaw. There is nothing 
in their outward appearance to distinguish them from a simple fibroma. In- 
ternally they have a softer consistence, and contain cell-forms which ally 
them with the sarcomata. The tendency to recur after removal confers on 
these formations a certain degree of malignancy which prevents them from 
being classed as benign neoplasms. 
Treatment.-Fibrous tumors of the lower maxilla, whether periosteal or 
osteal, should be removed, along with an ample amount of sound flesh or 
bone; in some instances they necessitate the excision of the entire half of 
the jaw. 
Sarcomata.-The recurring fibroids and the sarcomata of the jaw are only 
colossal forms of epulis, the histological elements being very much alike. 
The growth commences as a small swelling projecting from the gum into the 
mouth, having a red or livid color, growing steadily, displacing the teeth, 
filling the mouth, dislocating the lower jaw, and pushing out the face on the 
affected side. The cheek finally becomes blended with the growth, incorpo- 
rated with, or rather infiltrated with, its cellular elements, and finally may 
undergo ulceration, leaving sinuses through which protrude fungous masses 
of granulations. (.Fig. 1631.) In some cases, though the cheek and othei' 
soft parts appear to be a part of the tumor, on a closer inspection it will be 
found that the apparent oneness is only apposition. 
These growths are often found mingled with imperfect osseous matter, 
when they are called osteo-sarcomata; at other times they contain many 
polynucleated cells, giant cells, or embryonal cells, when they are classed as 
myelo-sarcomata. Occasionally they undergo a partial cystic transformation, 
when the term cystic sarcoma is employed to designate the disease. (Fig. 956 
SURGICAL DISEASES OF THE MOUTH. 
1632.) In all these varieties, however, the fundamental histological element 
is embryonal tissue in some form. 
Fig. 1631. 
Fig. 1632. 
Sarcoma of the lower jaw. 
Cystic sarcoma of the lower jaw. 
Diagnosis.-No diagnosis of these growths is reliable which is not based 
on a microscopical examination of the contents of the tumor. 
Treatment.-Whatever may be the variety of these tumors, nothing short 
of an early extirpation of the growth, along with that portion of the bone 
from which it springs, or, if necessary, the entire bone, will suffice. Even 
then its recurrence is not improbable. 
Enchondroma.-Cartilaginous tumors are not often met with in the lower 
jaw. They may be recognized by their irregularity or lobulated appearance, 
and by their density, occupying a place in this respect between fibromata 
and osteomata. Any part of the jaw may become the seat of these growths, 
though generally that part between the lateral incisor and the last molar 
is selected by the disease. It has both a periosteal and an osteal origin, 
acquires great bulk, and sometimes involves the entire half of the jaw. 
When of small size, enchondromatous tumors are made up of a number of 
cartilaginous masses bound together by intermediate bands of connective 
tissue, and are remarkable for the diversified forms of cartilage which enter 
into their composition. 
Treatment.-When small and occupying the surface of the bone, it will 
be sufficient to cut away the growth by a chisel or a Hey's saw. When 
much of the bone is included in the mass, nothing short of the removal of 
the former will suffice. When the operation has been thorough, no return of 
the disease need be anticipated. Maxillary enchondromata, when allowed to 
remain, cause death by pressure, interfering with respiration and deglutition 
by encroaching upon the larynx and oesophagus. 
Osteomata.-An enchondroma undergoes, in some instances, ossification, 
producing in this manner an osseous tumor. The structure of such a forma- 
tion, when exposed, exhibits a porous or spongy appearance, it retains its 
lobulated shape, and if its previous history is carefully elicited it will be 
found that the transformation was characterized by a progressive solidifica- 
tion, which was detectable by the pressure of the finger. There are bony 
tumors which have a peripheral and others which have a central origin ; 
that is, spring from the external surface of the periosteum of the jaw, or 
from the tissue between the compact walls of the latter. Those which grow AFFECTIONS OF THE ANTRUM AND UPPER JAW. 
957 
from the periosteum, or outer plate of bone, answer to wbat are usually 
termed exostoses; those which arise within the compact walls of the maxilla 
may be styled intra-osseous tumors. 
The osteomata of the jaw have all degrees of density, from a spongy tex- 
ture to an ivory hardness (eburnated or ivory osteoma). 
A differential test has been given by histologists to distinguish those osseous 
growths which are exostoses from those which develop in the more central 
portions of bone, namely, the perpendicular disposition in the former growths 
of the Haversian or vascular canals in continuity with those at the surface 
of the bone where the tumor is attached. 
Treatment.-Eburnated tumors having a superficial connection with the 
jaw can be successfully removed by the chisel or saw, but when involving 
the body of the bone the only effectual mode of disposing of them is to 
remove the corresponding portion of the maxilla. 
Carcinoma of the lower jaw is frequently encountered. The form most 
common is encephaloid or medullary cancer. Rarely do we meet with scirrhus, 
melano-carcinoma, or melano-sarcoma. The 
great frequency of carcinoma as compared 
with other tumors of the jaw will appear from 
an analysis made by Otto Weber of 403 mor- 
bid growths of the inferior maxilla, of which 
number 162 were cancer. 
Carcinoma, beginning in the central part of 
the bone, generally grows with great rapidity, 
separating the external laminae of the jaw, 
which soon give way, allowing the soft fun- 
gous mass to protrude into the mouth, and 
uniting to itself the adjacent soft tissues of 
the gum and the cheek in one indistinguish- 
able mass. On the surface of this, through 
ulcerated openings, grow several fungoid 
masses of soft, bleeding granulations (Fig. 
1633), accompanied with infection and en- 
largement of the lymph glands under the jaw 
and in the neck. 
In the diagnosis of encephaloid cancer of 
the jaw there are three signs which are en- 
titled to much weight: these are rapidity of growth, the implication of the sur- 
rounding soft tissues by the tumor, and the enlargement of the nearest lymphatic 
glands. 
Fig. 1633. 
Encephaloid cancer of the lower jaw. 
Affections of the Antrum and Upper Jaw. 
Inflammation of the lining membrane of the antrum, except as an exten- 
sion from the mucous membrane of the nasal fossa, with which it is continu- 
ous, or from diseased or displaced teeth, or the presence of a foreign body, 
must be exceedingly rare. I can recall no case of the kind. As a secondary 
condition, however, inflammatory troubles arise which terminate in abscess 
or dropsy. 
Abscess.-The roots of the first two molar teeth form a prominence in the 
floor of the maxillary sinus. An extremely thin layer of bone separates the 
two. It follows, therefore, that inflammation may be readily propagated to 
the lining membrane of the cavity if these roots are diseased. Not unfre- 
quently teeth find their way-particularly in cysts of the jaw-into the 
antrum, and, acting as foreign bodies, cause suppuration. Pus is sometimes 
found in the sinus independent of any inflammatory changes in its lining, 
as where an alveolar abscess breaks through its floor. 
Abscess may also arise from traumatic causes, as blows upon the face, or 
gunshot wounds. 958 
SURGICAL DISEASES OF THE MOUTH. 
Symptoms.-The early symptoms of abscess of the antrum are a deep- 
seated pain in the region of the sinus, occasionally radiating in different di- 
rections upward, outward, and downward in the lines of the branches of the 
second division of the fifth pair of nerves, and tenderness and swelling of the 
cheek. These symptoms, so often present in other affections of the upper 
jaw, would not justify the conclusion that an abscess existed. After a time, 
however, others of a more decisive character appear. 
The swelling of the face continues, to increase, with more or less oedema, 
but without any increase of tenderness. A sense of fullness is experienced 
in the jaw, as though something was exerting a centrifugal pressure. A 
chill, followed by some febrile disturbance, occurs, and finally pus begins to 
discharge from the anterior nares of the affected side, and, on exposing 
the cavity of the nose, may be seen to enter the lattei- from the side of the 
middle meatus. If from any cause the opening into the nasal fossa becomes 
obstructed, and the purulent collection continues to accumulate, the walls 
of the antrum will yield, either upward, pushing before it the floor of the 
orbit, in which case there will be some displacement of the eye and an in- 
crease of swelling at the upper portion of the cheek, or anteriorly, causing a 
marked projection of the cheek, with possibly a parchment-like crepitation of 
the facial wall of the sinus when subjected to pressure. 
In a case of abscess of the antrum under the care of Mr. Salter, in which 
the floor of the orbit was opened by the disease, the pus discharged on either 
side of the eye, causing the loss of the ball. 
Treatment.-A careful inspection of the teeth should be the first step in 
the treatment of an abscess of the kind under consideration. If any are 
found decayed or otherwise diseased, they should be promptly extracted, 
whether any defect is discovered in the teeth or not. The contents of the 
antrum must be evacuated, and this requires that an opening shall be made 
into its cavity. This can be effected by passing a drill through the anterior 
wall of the sinus where it joins the wall of the cavity, and will require the 
instrument to be entered on the inside of the mouth in front, where the 
mucous membrane is reflected from the cheek to the alveolus. If one of the 
molar teeth, preferably the second, is absent (and if not, then one may be 
extracted for the purpose), the perforation can be made still more satisfac- 
torily by passing a drill, or a trocar and canula, or the trephine of Pope, 
through the bottom of its socket into the cavity of the sinus. 
An opening made in this situation is admirably adapted for drainage, 
though more likely to admit particles of food and other substances into the 
antrum. After emptying the abscess, the cavity should be daily washed out 
with solutions of permanganate of potash, sulphate of zinc, or dilute tincture 
of iodine. Any one of these can be thrown into the sinus by means of a 
syringe having a nozzle suited to the size of the aperture, taking care after- 
wards to plug the opening with a little piece of wax, or a roll of wool 
secured to a thread, so as to prevent the intrusion of foreign matters into the 
sinus. 
Antracele, or dropsy of the antrum, consists in an accumulation of fluid in 
the maxillary sinus, giving rise to a painless expansion of its walls, and form- 
ing a considerable swelling over the corresponding portion of the face in 
well-marked cases of the disease. Nor does the anterior wall of the antrum 
alone yield, causing the facial enlargement, but the orbital, nasal, and pala- 
tine portions of the bone also give way, producing displacement of the eye, 
obstruction of the nasal passages, and bulging of the bard palate. It is quite 
common to find the facial wall of the sinus thinned out by absorption until 
it becomes flexible, and crackles, when pressed upon, like parchment. Often, 
indeed, the bone is entirely destroyed, leaving only the thickened periosteum 
and soft parts of the face in front of the swelling. 
Pathology.-The earlier views entertained with regard to the disease 
attributed it to mechanical causes. The dropsy was believed to be due to AFFECTIONS OF THE ANTRUM AND UPPER JAW. 
959 
the opening between the middle meatus of the nose and the sinus becoming 
closed, in consequence of which the secretion of the cavity, not being allowed 
to escape, accumulated so as to form the enlargement. By Adams, Giraldes, 
and Luschka, who have made this affection a subject of special investi- 
gation, the disease is regarded as a cystic degeneration of the glands of the 
mucous lining. While this is doubtless correct in many instances, it will 
not hold good in all. These accumulations in the antrum have a wider 
causation. 
There is a remarkable difference in the appearance of the fluid found in 
the sinus. It sometimes resembles in its physical and chemical characteris- 
tics that of a hydrocele or an ascites, thin, straw-colored, and coagulable by 
heat. Sometimes it is thick and glairy, having the consistence of a syrup ; 
at other times it is purulent, may have a yellowish-white color, and resembles 
the soft or semi-fluid contents of a sebaceous cyst. Crystals of cholesterin are 
also found in the liquid contents of these enlargements. Some of these appear- 
ances are doubtless the result of degenerated changes in the liquid formations, 
rendering the latter very unlike what they were originally. Conditions so 
diverse are not always the products of cystic disease; frequently they arise 
from chronic inflammation and states of the lining membrane of the antrum 
provoked by various irritants propagated from the nasal mucous membrane, 
or connected with the roots of the teeth and with errors of dentition. Sev- 
eral instances of the disease have been witnessed in which a tooth had entered 
the sinus and produced the inflammatory accumulation. In other cases an 
abscess of the alveolus or a dentigerous cyst has opened into the antrum and 
given rise to the affection. 
The diagnosis of antracele is not attended with any difficulty after the 
walls of the sinus have become much attenuated or have been absorbed, as, 
under these circumstances, it is not difficult to recognize the presence of fluid 
contents. If any uncertainty should exist, however, it will be well to intro- 
duce an exploring needle to remove the obscurity. Unless such favoring 
circumstances exist, it is possible to confound the dropsy with growths of a 
more solid nature. I have seen a surgeon lay open the cheek preparatory to 
removing the superior maxilla for what was supposed to be a fibrous tumor, 
when, after uncovering the bone, the anterior wall of the antrum gave way, 
discharging a large quantity of straw-colored serum, the presence of which 
constituted the tumor. 
Treatment.-The treatment of antracele is not, usually, attended with 
any difficulty. A free opening should be made into the sinus, between the 
cheek and the gum, with a knife, or, if the bone is too thick to be divided in 
this manner, then with a drill, always enlarging the orifice by nipping away 
the bone around the opening with pliers until the little finger can be in- 
sinuated into the sinus. A digital exploration should never be neglected, 
otherwise it is impossible to determine with certainty whether the disease 
arises from cystic inflammatory causes, or from the presence of a tooth. 
After emptying the contents of the antrum and removing any foreign 
body which may be discovered, or breaking up any cysts, its cavity should 
be injected every second or third day with a solution of sulphate of zinc, 
five grains to the ounce of water, or a solution of sulphate of copper of the 
same strength, or tincture of iodine half the officinal strength. 
Fistulous Opening.-After an operation on the maxillary sinus, or in con- 
sequence of a diseased tooth, a fistulous opening may remain, through which 
a little pus or muco-pus issues. Many persons allow an orifice of this 
kind to remain for years, plugging it up in the intervals of cleansing with 
a little stopper of pine wood, in order to obviate the annoyance of the fre- 
quent discharge of matter into the mouth. 
When a fistula persists in this manner, either the cause of the original 
disease has not been removed, or there is some defect in the drainage. The 
remedy lies in making a free and direct opening into the cavity, and, after re- 960 
SURGICAL DISEASES OF THE MOUTH. 
peating the exploration, injecting tincture of iodine of full strength. When 
the fistula opens through the alveolus, any diseased tooth-roots which may 
be present must be extracted preliminary to injecting. 
Tumors of the Antrum. 
There are two forms of morbid growths found in the antrum : one consist- 
ing of hypertrophied glands, or glands undergoing cystic degeneration, as 
described by Giraldes, and the other histologically allied to tubular epithe- 
lioma. The last is a recurring, and doubtless a malignant, neoplasm. 
Commencing in the antrum, these tumors, especially the latter variety, 
after expanding the walls of the cavity in all directions, and giving rise to 
singular distortions and deformities of the face, grow into the nose, obstruct- 
ing the nasal cavities, and are often confounded with nasal polypi. They 
may occasion, also, absorption of the osseous walls of the sinus, and protrude 
into the mouth, the pharynx, or the base of the skull. 
Treatment.-They require for their extraction the removal of the ante- 
rior walls of the antrum. When feasible, this should be done through the 
mouth, without opening the face, by dissecting the soft parts from the jaw 
and cutting the latter away. 
Tumors of the Upper Jaw. 
The tumors which develop in the upper jaw are of the same nature as 
the morbid growths of the lower maxilla, though their effects are more 
serious and they cause greater deformity. 
The most common varieties of tumors affecting the upper jaw are sar- 
coma, carcinoma, and osteoma. Enchondroma, fibroma, and cystoma are 
comparatively rare. 
Sarcoma, answering to the fibro-plastic tumor of Lebert, commences either 
on the external surface or the interior of the upper jaw, in the same manner 
as does the so-called epulis, and generally grows with rapidity, causing de- 
struction of the osseous tissue, from which, or in the midst of which, it de- 
velops. When the tumor has its origin within the substance of the bone, it 
constitutes myelosarcoma. 
Sarcoma of the jaw appears as a dense, oval, oblong, or irregular enlarge- 
ment, the form being determined by the resistance of the superincumbent 
tissues, and by the superficial or central origin of the disease. 
It is not, at first, accompanied by any pain. As it grows, the overlying 
parts become stretched, forming a tumor either on the inside of the mouth, 
covered by the tissues of the gum or the mucous membrane, or on the jaw, 
over the canine fossa; or the tumor occurs on the face if the disease is seated 
higher up on the jaw, producing a prominence of the cheek or of the side of 
the nose. 
The disease, in its progress, often causes, when central, expansion and 
parchment-like thinning of the bone, or, if developing inward, produces de- 
struction of the walls of the antrum, entering that cavity, and from thence 
spreading in all directions, displacing the eye, and extending into the nasal 
fossa?, mouth, and pharynx, sphenoid cells, pterygo-maxillary and temporal 
fossae,-indeed, into every inequality between the bones of the face and those 
of the skull,-and causing the most repulsive and unnatural deformities. 
(Fig. 1634.) It is singular to what extent the soft parts of the face are often 
stretched by a sarcomatous tumor without becoming incorporated with the 
growth or undergoing ulceration. Only in rare cases does this follow. 
The histological elements of maxillary sarcomata differ somewhat accord- 
ing to the original seat of the tumor. When originating from the periphery 
of the bone, the formed elements are chiefly round and spindle-shaped cells; 
and when developing centrally or in the interior structure of the jaw, the TUMORS OF THE UPPER JAW. 
961 
myeloid, or embryonal, and multinuclear giant-cells prevail. The interior 
of these tumors is often filled with cysts. The first variety of sarcoma oc- 
curs in early adult life; in the latter the 
subjects are more advanced, about or 
after the age of forty. 
When ossification takes place in a sar- 
coma, though, as in smaller growths else- 
where, it is usually incomplete, no perfect 
bone being formed, yet the tumor is often 
termed an osteo-sarcoma. 
Diagnosis of sarcoma of the upper jaw 
is a matter of presumption rather than 
of certainty. When a growth of the 
maxilla makes its appearance before 
mature life and increases rapidly; when 
its surface is irregular, crepitates on 
pressure, and presents here and there a 
soft, probably a fluctuating, spot, espe- 
cially if there is no tendency to ulcera- 
tion of the soft tissues of the check, there 
are reasonable grounds for regarding the tumor as a sarcoma. 
Treatment.-Nothing short of excision of the entire bone involved in 
the disease will avail; and even then its recurrence need not cause any 
surprise. 
Fig. 1634. 
Sarcoma of the jaw.-From the museum of the 
University of Pennsylvania. 
Carcinoma.-Carcinoma is much more common in the upper than in the 
lower jaw, and is almost invariably of the encephaloid character. No period 
of life is exempt from the disease, nor is it a respecter of sex, male and female 
suffering with like frequency. It has no fixed point of origin, commencing 
in the body of the bone, on the walls of the antrum or within its cavity, or 
in any portion of the jaw or its periosteum. 
Carcinoma may exist some time before it is recognized, being concealed 
in the antrum or in the zygomatic recess of the skull. In these locations 
it gives rise to obscure and unintelligible pains before making any external 
show. 
The common history of a case of carcinoma begins with the appearance of a 
small, hard tumor,-at first painless, afterwards painful,-occupying some por- 
tion of the upper jaw, projecting downward between the cheek and the jaw, or- 
outward, upon the side of the face. When the disease begins in the antrum 
or over its external wall, or even in the cancellated tissue at the base of the 
alveolus, it develops in different directions, generally first in that in which the 
least resistance is encountered. Thus, it may grow into the nasal cavities, or, 
pushing off the orbital plate of the superior maxillary, encroach upon the 
orbit and cause displacement or even destruction of the ball of the eye. Or 
the horizontal plate of the same bone may be expanded, and the tumor, covered 
by the tissues of the hard palate, project on the roof of the mouth. Sometimes 
the direction of the alveolar border of the jaw is changed, assuming a some- 
what horizontal position, with the teeth directed outward. As the growth 
advances, the cheek, lips, and ala of the nose become swollen and oedematous 
(Fig. 1635) ; the compact lamella of the bone, gradually undergoing absorp- 
tion, finally gives way ; a fungous, bleeding growth projects into the mouth 
or the nose, extending at length into the various sinuosities at the base of 
the skull; the breathing becomes noisy, and deglutition difficult; the saliva 
dribbles from the mouth, while the articulation is wholly guttural. As the 
pressure at the base of the cranium increases, the patient suffers from drowsi- 
ness and stupor, dropping into a snoring sleep even in the midst of conver- 
sation. The discharges from the proliferating masses of fungoid granulations, 
consisting of blood and ichorous pus having an offensive odor, aid in poison- 
ing the general system, the implication of which becomes visible in the en- 
voi.. ii.-61 962 
SURGICAL DISEASES OF THE MOUTH. 
largement of the lymph glands of the neck, in the dirty hue of the skin, and 
in the emaciation and loss of strength which precede the fatal termination 
of the disease. 
Carcinoma commencing in the antrum or in the cancelli of the bone does 
not run its course with the same rapid- 
ity as when it begins on the surface of 
the jaw. The resistance of the osseous 
walls in which it is imprisoned serves 
to restrain its growth and prolong life. 
I have twice seen patients undci* these 
circumstances live for twelve years, 
until, indeed, from the magnitude of 
the growth, the face had lost all traces 
of humanity and was transformed in 
appearance into that of a beast. 
The signs which indicate a tumor of 
the jaw to be carcinomatous are the 
presence of lancinating pains, the rapid 
implication of the skin, the tendency 
to ulcerate and to push out fungous, 
bleeding, and fetid granulations, with 
contamination of the lymphatic glands 
and the early appearance of a cachexia. 
Rapidity of growth, of itself, is not an 
important diagnostic sign, as there are 
other tumors of the jaw, particularly 
sarcoma, which increase as rapidly as carcinoma. In all cases the ex- 
ploratory use of the needle is desirable, obtaining thereby some of the 
contents of the tumor with a view to subject them to a microscopic exam- 
ination. 
The minute structure of these growths does not differ from that of medul- 
lary cancer in other parts of the body, being made up of alveolar arrangements 
of connective tissue, the cavities being occupied by variously-formed cells 
and richly supplied with blood-vessels. 
Incisions should not be made into these neoplasms, as they merely open a 
way for the protrusion of a mass of bleeding and fetid fungus. 
Treatment.-As maxillary carcinoma is rarely found associated with can- 
cer in other parts of the body, there is in its apparently local origin a 
great temptation to early operations,-a course which has never received 
my sanction. In advising or practicing operations for this disease I have 
always been governed by the following rules. When the disease is making 
slow progress and manifests no tendency to contaminate the soft parts, 
abstain from using the knife. When the growth, on the contrary, shows a 
disposition to run an acute course, or is situated in the antrum, and the walls 
have given way at one or more points, then let the maxillary bone be re- 
moved in its entirety. When the tumor has existed for some time, and there 
is every evidence that the growth has extended beyond the limits of the jaw 
into the deeper recesses behind the bone or into the nasal fossae; when the 
soft tissues of the face have become diseased and adherent to the morbid 
mass ; or when the lymph glands have become tender and enlarged, operation 
is useless, and, in my judgment, only tends to shorten life. Under any 
circumstances the disease will return. 
Fig. 1635. 
Carcinoma of the upper jaw. 
Fibroma.-Fibrous tumors of the upper jaw are quite uncommon, although 
frequently met with in the lower maxilla. Like other neoplasms of the jaws, 
they may have either a peripheral or a central origin, or may begin in the 
antrum or upon the palatine plate of the maxilla. When recognized in the 
antrum, or as growing from some central point of the jaw, there is some 
uncertainty as to their true origin, since they possess a tendency to develop TUMORS OF THE UPPER JAW. 
963 
through the small fissures connecting with the cavities of the maxilla, the 
latter becoming only secondarily involved. 
This disposition to wander is, however, by no means an early character- 
istic of the tumor when its original seat is in the jaw. On the contrary, 
while it may attain a large bulk, it manifests little disposition to extend 
beyond the bone where it has fixed its seat. The tumor grows slowly, is 
dense, but hot painful, has a lobulated form, and exhibits no tendency to 
ulcerate or to contaminate the system. When growing from the surface of 
the jaw, the base is usually broad, and does not penetrate into the bone ; 
when seated in the antrum or cancellated structure, the walls of the bone 
are expanded and thinned as the growth increases in size. The prominent 
surfaces of the tumor are generally those towards the face and alveolar 
border and hard palate, though in that case the growth will trench on the 
orbit and the nose. When the mass has attained considerable size, patients 
will often complain of neuralgic pains in the face, temple, and ear. 
These tumors are made up of dense masses of white, shining, fibrous tissue, 
having few blood-vessels, the different lobules being united together and the 
exterior of the tumor covered or inclosed with the same material, though 
compact in the arrangement of its fibres. 
They are often interpenetrated with splinters or small nodules of calcareous 
matter. 
The diagnosis of fibroid tumors of the upper jaw is based on their slow- 
ness of growth, their bard, irregular, nodulated surface, the continued absence 
of pain, the healthy state of the adjacent structures, and the absence of any 
tendency to invade the underlying bone, to undergo ulceration, or to cause 
glandular enlargement or constitutional contamination. 
Treatment.-These tumors, when of limited size, can often be enucleated 
by cutting down on their surfaces; and, if possible, this should be done without 
opening the cheek or detaching the soft parts, an operation which, in conse- 
quence of their sinking into all the irregularities of the tumor, is often quite 
tedious and difficult. The cutting out is done with a saw and chisel. When 
springing from the periosteum, they can be detached from the bone by cutting 
through the dense fibrous tissue with which they are surrounded and prying 
the mass off without disturbing the jaw at all. Enucleation is often practi- 
cable when the tumor occupies the antrum, requiring only that its surface 
shall be thoroughly uncovered in order to give free access to the cavity. 
If we could always be certain that the growth was simply a fibroma, such 
a course would be preferable. This not being the case, it is better, especially 
if the growth has implicated much of the jaw, to remove the latter in its 
entirety, leaving, if possible, the orbital plate. I am not in favor of gouging 
operations for the removal of morbid growths of the jaws, unless they are 
very circumscribed and entirely benign in their nature. It is greatly prefer- 
able to make clean sections of the bones, even if a little more of the jaw is 
taken away than might possibly have been required, the error being usually 
in the other direction. 
If the tumor is purely fibrous, no return may be anticipated; but should 
it contain any myeloid or sarcomatous cell forms, its return will not be im- 
probable. 
Enchondroma.-Cartilaginous tumors have rarely been seen on the jaws. 
Heyfelder has found in 450 cases of diseases of the jaws 8 eases of enchon- 
droma. A few cases have been recorded by Morgan,* Beaumont,f O'Shaugh- 
nessy,J Heath,§ Beck, and others. 
The favorite seat of enchondroma of the jaw is on the anterior face of the 
bone, or somewhat near the nose (Fig. 1636), commencing in the deeper layer 
of the periosteum. These tumors are prone to undergo osseous transforma- 
* Guy's Hospital Reports, vol. i. 
f Royal Medical and Chirurgical Society's Transactions, vol. xxxiii. p. 243; Holmes. 
J O'Shaughnessy on the Bones. £ Heath on Injuries and Diseases of the Jaws, p. 244. 964 
SURGICAL DISEASES OF THE MOUTH. 
tions. Of this nature were those recorded by Beck, Hancock, and Collis. 
They may grow to a large size. 
The most remarkable example of 
this kind is the one given by 
O'Shaughnessy, which in a sin- 
gle year attained the weight of 
four pounds. 
The diagnosis of enchondroma 
must necessarily be uncertain, the 
best indication being the density 
of the tumor, which is between 
that of an osseous and that of a 
fibroid growth; but this is entirely 
too fallacious a sign to merit much 
consideration. An enchondroma 
does not materially differ in ap- 
pearance or external characteris- 
tics from other tumors of the jaws, 
-a fact which aids in rendering 
the diagnosis a matter of some 
uncertainty, particularly in the 
early stages. 
Treatment. - Early removal 
should be practiced, including a 
portion of the bone on which the growth rests, for without such precaution 
its reproduction is probable. In a case recorded by Heath, the tumor had 
been previously excised on three occasions, once by Mr. Le Gros Clark, once 
by Mr. Partridge, and once by Professor Gunn, of Ann Arbor, Michigan, to 
which place the patient had come from England. The disease again appear- 
ing, the patient returned to England, where he was operated on a fourth time, 
by Mr. Heath, but died, not from the operation, but some time following, 
from an attack of erysipelas. 
Fig. 1636. 
Enchondroma of the upper jaw.-From a cast in the museum 
of the University, Smith's collection. 
Osseous Tumors.-Bony tumors of the jaw occur in two forms, growing 
either from a circumscribed surface of the maxilla or from its cancelli. 
The first may be regarded as an exostosis. On several occasions I have 
seen such tumors on the bard palate, which became quite troublesome and 
sore on account of the friction to which they were subjected in masticating 
the food. In two of the cases, though under my observation for several 
years, I have not been able to notice any marked increase. 
An osteoma occupying the facial surface of the 
upper jaw will produce much deformity. (Fig. 
1637.) 
A very remarkable instance of a large bony tumor 
which underwent spontaneous separation from the 
jaws is recorded by Mr. Heath. Its detachment 
appears to have been brought about by caries of 
the bone around its base. When the osseous for- 
mation is more general, the disease would be more 
clearly expressed by the term hypertrophy. 
The entire maxilla or any part of the bone may 
become the seat of such enlargement. It is seen 
in the tuberosity, and may extend to the alveolar 
process of the jaw. (Fig. 1638.) In one case, that 
of M. Michon, an osseous tumor grew from the 
lower surface of the orbital plate of the frontal 
bone, filling the antrum. In another case, that of 
Dr. Duka, also recorded by Heath, the tumor had 
become detached from its bony origin, and lay loose in the antrum. 
Fig. 1637. 
Bony tumor of the upper jaw. EXCISION OF THE JAWS. 
965 
The structure of osteomata of the jaw is either hard, dense, or ivory-like, 
or soft and spongy. Those which partake of the character of exostosis are 
generally more compact than those which commence centrally. They seldom 
Fig. 1638. 
Hypertrophy of the tuberosity of the upper jaw. 
appear before middle life. Bony tumors are usually slow of growth, are ex- 
tremely hard and irregular on their surfaces, devoid of pain, show no tend- 
ency to ulcerate, and become serious only when, from their bulk or location, 
they are obstructive to the nose, mouth, orbit, or the movements of the jaws. 
The causes which are influential in producing tumors of the upper jaw are 
the same as those which give rise to similar diseases in the lower maxilla, 
namely, disorders of the teeth, and sometimes blows upon the face, clearly 
indicating an inflammatory origin. 
Treatment.-When small, causing no inconvenience, and showing no tend- 
ency to grow, no surgical interference is necessary; but when the reverse is 
the case, they should be excised. When limited to a portion of the jaw, or 
when occupying the antrum, the removal can be effected by the aid of chisel, 
gouge, bone forceps, and pliers, and a small saw, but much more satisfactorily 
by the disarticulation of the maxilla. When the disease assumes the form 
of a diffused hypertrophy, it will be necessary to extirpate the entire jaw, 
always leaving in this, as in every operation of the kind, the orbital plate of 
the bone, if possible. 
There is a general hyperostosis of all the bones of the face, which produces 
a singular change or deformity of the face,-the osseous leontiasis of Virchow. 
Cases of the kind have been reported by Howship, Gruber, Bickersteth, and 
Sir Astley Cooper. Heath mentions one in which the hypertrophy was uni- 
lateral. This disease is possibly the result of inflammatory causes, and, when 
general, admits of no remedy. 
Excision of the Jaws. 
History.-The removal of the whole or portions of the maxilla in cases 
of morbid growths affecting the jaws has become a recognized and well- 
established surgical procedure. To Deadrick,* of Tennessee, in February, 
* Medical Recorder, vol. vi., 1826. 966 
SURGICAL DISEASES OF THE MOUTH. 
1810, the profession became indebted for the first partial resection of the lower 
maxilla. The patient was a boy who had an enebondroma attached to the 
left side of the lower jaw. The growth had increased to such a degree as to 
interfere with deglutition, and demanded surgical interference. The tumor 
was exposed by two incisions through the cheeks, the one running obliquely 
from the zygoma to the chin, and the other extending from the middle of the 
first incision, vertically, to a point below the middle of the jaw. The bone 
was cut through at the symphysis and a little in advance of the angle, thus 
removing the entire body or horizontal portion of the maxilla, with the tumor 
attached. The patient made a rapid and permanent recovery. 
In 1812, Dupuytren* removed the body of the lower jaw from angle to 
angle on account of a cancerous tumor. 
There is an excision of one-half of the lower jaw attributed to Mr. White, 
surgeon to the Westminster Hospital, which was performed in Cambridge, 
England, in 1812. From the description given of the case by South, it would 
appear to have been removed on account of necrosis. 
The operation was repeated in 1821 by Valentine Mott,f of New York. 
In the same year Von Graefe excised the anterior part of the jaw in the 
case of a cancerous disease occupying this part of the bone. A small por- 
tion from the surface of the maxilla at the symphysis, not including the 
entire thickness of the bone, was excised by Sir Astley Cooper§ in 1818. In 
1823, George McClellan, of Philadelphia, excised all that part of the jaw be- 
tween its angles. It would appear that in England the first removal of the 
inferior maxilla on account of a morbid growth was performed by Wardrop.|| 
The first total excision of the lower maxilla was made by Signorini, and 
soon after, in 1843, the operation was done by Heyfelder, of Erlangen. Fol- 
lowing these came the operations of Professors Carnochan and Wood, of 
New York, and, in 1850, that of Professor Ackley, of Cleveland, Ohio. 
The first partial excision of the upper jaw is ascribed to Acoluthus, a 
surgeon of Breslau, in 1693. With the exception of the very slight opera- 
tion executed by Jourdan on the antrum, in 1768, and the more extensive 
one of Dupuytren on the alveolar process, in 1819, the next extensive re- 
section of the upper jaw, in which all the bone was removed except the 
orbital plate, "was performed in this country by Dr. Jamison, in 1820. 
A still more daring excision was practiced four years later, in September, 
1824, by Dr. D. L. Bogers,of New York, wTho removed both upper max- 
illae, leaving only the tuberosity of each. 
A similar operation was done the following year by Dr. Alexander Stevens, 
also of New York,** in which not only the entire maxillary was removed, but 
along with it the malar and partially also the sphenoid and ethmoid bones. 
This case was not made public, owing to personal objections on the part of 
the patient, until 1840. 
The credit, however, of first removing the entire superior maxilla along 
with the malar bone was generally at the time conceded to Gensoule, Hotel- 
Dieu, Lyons, France, his case having been published. This operation was done 
in 1827, though it had been proposed by Lizars one year previously,-in 1826. 
Lizars, in his first attempt to remove the upper jaw in a case of carcinoma, 
was obliged to abandon the operation on account of hemorrhage; but in 
1829, and again in 1830,he was more successful, having excised the superior 
maxilla twice. In 1842 the upper jaw was again excised, by Mussey, of Cin- 
cinnati, and by Warren, of Boston. In 1844 the first complete excision of 
both upper maxilla? was executed by Heyfelder, and in 1848 Dieffenbach 
* Lancet, vol. i. p. 56, 1831. f Gibson's Surgery, vol. ii., 1827. 
| Jahresbericht des Chirurgisch-Augenarztlichen Institutes an Berlin, Graefe und Von Walther, 
Journal, vol. iii. p. 256, 1822; Chelius. 
# Cooper and Travers's Surgical Essays, Part I. p. 179, 1818; Chelius. 
|j Lancet, vol. ii. p. 27, 1826-27. 
•f New York Med. and Phys. Journal, September, 1824. 
** New York Journal of Medicine, New Series, vol. vi., 1851, p. 308. 
ft Lancet, vol. ii., 1829-30. RESECTION OF THE LOWER JAW. 
967 
removed, in addition to the major part of both these bones, the malar and the 
palatine pieces. These pioneers having thus opened the way in this depart- 
ment of bone surgery, their example has been followed by almost every 
surgeon of any experience. 
Resection of the Lower Jaw. 
When it is desired to remove a portion of the alveolus, there will be re- 
quired a scalpel, one or more tooth forceps (Fig. 1639), a metacarpal saw 
Fig. 1639. 
Lion forceps. 
(Fig. 1640), and two strong bone pliers (Fig. 1641), with retractors (Fig. 1642), 
and a chain saw. 
In all operations upon the maxillae, upper or lower, full anaesthesia should 
be kept up only during the extraction of the teeth and the incision and dis- 
Fig. 1640. 
Metacarpal saw. 
section of the soft parts of the cheek. When the process of disarticulation 
commences, it is better that the patient be not too profoundly affected, as 
the blood may pass into the larynx. Frequent cleaning out of the pharynx 
Fig. 1641. 
Cutting bone pliers. 
with sponge mops, properly secured in the grasp of a sponge-holder or to 
long pieces of wood, must be diligently kept up. 
Operation for partial excision.-The patient being seated on a chair, an as- 968 
SURGICAL DISEASES OF THE MOUTH. 
sistant stands behind and supports the head against his breast, while with a 
hand at either angle of the mouth he everts and depresses the lip, holding it 
Fig. 1642. 
Retractors 
out of the way of the operator. Or the patient may lie on a reclining chair, 
which is still better than the sitting posture. 
Supposing the disease to be a fibro-sarcoma occupying half an inch of the 
alveolus, the soft tissues of the gum should be divided down to the bone on 
all sides of the tumor, and sufficiently distant to be outside of the limits of 
the disease. With the metacarpal saw two vertical cuts of the alveolus are 
next made, answering to the lateral incisions of the gums, extracting, if 
necessary for the purpose, any teeth which may be in the way of the saw. 
As soon as the jaw has been divided down through the alveolus to its body, 
the bone pliers should be applied horizontally, and the diseased piece cut out. 
The vertical cuts are sometimes made with the angular-bladed pliers instead 
of with the saw; but the lines of division are prone to deviate from the 
proper course, or splintering of the bone may occur. 
Excision of the middle of the bone.-The most convenient method of re- 
moving the middle of the jaw is the following. Transfix the middle of the 
lower lip with a sharp-pointed bistoury, at its junction with the chin, cutting 
directly upward to its free border; next prolong the incision downward to 
the lower edge of the chin, and then horizontally for a short distance on 
each side along the base of the jaw. Dissecting the flaps from the bone, a 
perfect exposure of the middle of the maxilla is made for some distance on 
each side of the symphysis. A stout needle, having attached to it by a ligature 
one end of a chain-saw, is now to be passed from below upwards on the inner 
side of the jaw. 
As soon as the point of the needle appears on the surface, it is to be seized 
and drawn through, followed by the chain-saw. The needle being detached, 
the handle of the saw is to be attached, and the bone sawed through from 
within outward, previously removing any teeth which may interfere with 
the section. The bone is to be treated in a similar manner on the other side, 
when, being thus disconnected with the lateral portions, it can be dissected 
away from its attachments to the mucous membrane and the genio-hyoid, 
genio-hyo-glossi and digastric muscles. 
As all the anterior muscular connections of the tongue are severed, care 
must be taken, before the detachment is complete, to prevent the possible 
retraction of the organ against the glottis, by introducing a silk thread or 
silver wire through its under surface where it is entered by the genio-hyo-glossi 
muscles. After securing any vessels which require the ligature, the flaps 
are to be brought together, and the sides of the lip attached by the twisted 
suture, and the remaining portions of the wound by interrupted sutures. 
The jaw may be divided in another way, by sawing partially through the 
bone with a small saw, and cutting the remainder with strong bone pliers. 
I have also divided the maxilla with great rapidity by means of a small 
circular saw driven by a dental engine. 
Excision of one lateral half of the inferior maxillaryA growth may involve 
so large a portion of the jaw as to require the removal of the entire bone on 
one side. 
The first step in the operation is to uncover the tumor and at the same RESECTION OF THE LOWER JAW. 
969 
time expose the jaw. With these objects in view, two incisions have been 
devised. That of Lizars, of Canada, consists in dividing the cheek from a 
short distance in front of the ear to the commissure of the mouth and reflect- 
ing the inferior flaps. The other, which, in my judgment, is much to be pre- 
ferred, is made as follows: selecting a point three-quarters of an inch in front 
of the ear, and on a line extending from its lobe to the anterior naris, carry 
an incision directly down upon the masseter muscle, over the ramus, to the 
angle of the jaw, from thence along the base of the latter to the symphysis 
menti, and then directly upward over the chin and through the lower lip, 
stopping a little short of its red border, which need not be severed. 
The object of locating this first cut, as I have directed, over the ramus, is 
to avoid the parotid gland where it overlaps the masseter muscle, and also 
the parotid duct. The facial artery will be divided in the horizontal portion 
of the cut, and must then be tied. By passing a pin beneath the vessel where 
it reaches the jaw, and making a few figure-of-eight turns with a thread 
preliminary to making the incision, bleeding from this source may be pre- 
vented. The soft parts covering the horizontal parts of the jaw are now to 
be dissected up, exposing this portion of the bone or the tumor which cor- 
responds to it, from the ramus to the symphysis. This done, the insertion of 
the masseter muscle is next to be separated from the ramus or the growth, 
either with a knife or, preferably, with an instrument resembling a perios- 
teal elevator. (Fig. 1643.) The next step consists in dividing the maxilla 
Fig. 1643 
Dissecting elevator. 
at the symphysis with a saw, after which it is to be grasped with the fingers 
and drawn outward. The soft parts at the same time are detached from its 
inner face by a blunt-pointed bistoury, or, if the periosteum is in a state to be 
preserved, by the elevator, peeling it off along with the other tissues of the 
floor of the mouth. 
When the insertion of the internal pterygoid muscle is reached, it can be 
disengaged from the ramus with the same instrument, after which the jaw 
can be moved with much greatei* freedom. 
Returning again to the external surface of the ramus, repeat the operation 
upon the masseter muscle and other soft parts up to the sigmoid notch, keeping 
close upon the bone. It remains now to detach the temporal muscle from 
the coronoid process, and the condyle from the external pterygoid muscle 
and the ligaments of the temporo-maxillary joint, in order to complete the 
disarticulation. This is by far the most difficult part of the task. It is 
desirable to avoid injuring the internal maxillary artery, which lies on the 
inside of the neck of the condyle. To effect these ends, let an assistant with 
a retractor draw the upper angle of the wound forcibly upward, while 
the surgeon, using the jaw as a lever, carries its horizontal arm strongly 
backward until the coronoid process appears below the zygoma and becomes 
accessible. While holding it in this position, he can pass a probe-pointed 
bistoury into the wound, and sever the tendon of the temporal muscle from 
behind forward. The detachment may also be accomplished by the elevator, 
the bone being turned in different directions, so as to present the different 
surfaces of the process to the edge of the instrument. The knife, however, 
is more expeditious. 
The coronoid process once freed, the last step of the operation may be 
taken by carrying the jaws still farther back, causing the condyle to project 
strongly forward, when, its ligaments and the tendon of the pterygoid muscle 
being brought into view, they can be divided with the blunt-pointed bistoury, 
the first from before backward, the last from below upward. (Fig. 1644.) 970 
SURGICAL DISEASES OF THE MOUTH. 
When one-half of the jaw is taken away, the remaining half is liable to 
be drawn inward to a degree which interferes with mastication and the 
proper use of the tongue. 
The evil can be remedied by 
applying a denture between 
the jaws with caps to receive 
the teeth, thus making the 
upper jaw perform the office 
of a splint to the lowTer jaw. 
When the disease stops 
short of the ramus, the bone 
may be sawed through imme- 
diately behind the angle. 
Excision of the inferior max- 
illa.-In removing the whole 
of the lower jaw, it will be 
necessary to repeat the inci- 
sion employed for unilateral 
excision, as already described, 
and, after denuding the max- 
illa at the symphysis, remove 
each half separately. 
Barton proposed, when the 
disease did not involve the 
entire body of the maxilla, 
to divide the bone horizontally with a saw, leaving a rim of osseous tissue 
answering to its lower border, and thus preserve the contour of this portion 
of the face. The suggestion is an ingenious one, but in malignant affections 
should not be adopted. 
Results.-Dividing excisions into three classes, Heyfelder has collected 286 
cases, 188 of which recovered, 77 died or had a return of the disease, and in 
21 the result was undetermined. Of 15 coinplete excisions,-and by "com- 
plete" is meant the removal of the inferior maxilla in its entirety,-14 were 
cured and 1 died; of 133 unilateral excisions, 90 recovered and 43 relapsed 
or died; while of 138 partial excisions, 84 recovered, 33 relapsed or died, and 
in 21 the result was unknown. 
Hunter has collected 121 cases of resection of the lower jaw, 105 of which 
recovered and 16 died. Classifying these cases in a similar manner with 
Heyfelder's, there were 9 complete excisions of the lower jaw, with 6 recoveries 
and 3 deaths; 45 unilateral excisions, with 36 recoveries and 9 deaths or 
relapses; and 67 partial excisions, with 63 recoveries and 4 deaths. 
Excision of the upper maxilla.-The removal-complete or partial-of the 
upper jaw is an operation very frequently demanded on account of different 
morbid growths both of the maxilla and of the antrum. Though forming 
the skeleton of so large a portion of the face, it is remarkable how slight 
is the deformity which follows the excision of an upper maxilla. When, in 
consequence of necrosis, the removal of the bone becomes necessary, the sub- 
periosteal method should be employed, as a firmer basis of support will be 
obtained for the soft parts of the face, even though the new bone which is 
formed is imperfect and in isolated nodules. 
The instruments necessary for the excision of the upper maxilla are one 
or two scalpels ; two strong bone pliers, one straight and the other angular; 
a pair of lion forceps; and an Adams saw. 
Complete excision of the upper maxilla.-The upper maxilla can be exposed in 
three ways, every one of which furnishes ample space for the exarticulation 
of the bone. The first, commonly known as that of Lizars, consists in cutting 
through the cheek by an incision carried from the angle of the mouth to the 
malar bone. In the second method, or that of Liston, the incision is made 
from the angle of the mouth to the external angular process of the frontal 
Fig. 1644. 
Excision of the lower maxillary bone on one side. RESECTION OF THE LOWER JAW. 
971 
bone. In the third, that of Fergusson, two incisions are made, one longi- 
tudinally, extending from the inner angle of the eye to the outer limit of the 
orbit, parallel with and a little below the 
infraorbital ridge, and the other commencing 
at the nasal extremity of the first, and car- 
ried down along the side of the nose, around 
its ala to the columnte nasi, and from thence 
down to the middle of the upper lip. (Fig. 
1645.) 
When employing the method of Lizars or 
that of Liston, care must be taken not to go 
to the anterior edge of the masseter, at a 
point on a line from the anterior naris to the 
lobe of the ear, otherwise the duct of Steno 
may be wounded. The incision which I 
employ is that of Fergusson, dividing the 
lip, however, not in the middle, but midway 
between the middle and angle of the mouth, 
as represented in the cut. When the lip is 
divided in the middle, there is apt to follow 
in the healing a little depression of the red 
border where, naturally, there should be a 
slight prominence; and this detracts from 
the appearance of the lip. 
The advantages of the Fergusson incision are-first, the flap is below and 
out of the way of the operation; second, there is no danger to the parotid 
duct; third, the cicatrix, after healing, is in shade, and therefore less notice- 
able than when lying across the cheek; and, fourth, the arteries and nerves 
are severed near theii' extremities. 
The operation may be divided into four stages,-namely, exposing the 
bone; separating it from its adjoining connections; wrenching it from its 
position ; and closing and dressing the wound. 
First stage.-Assuming, then, that the maxilla is to be extirpated by this 
plan, let the flap, as the first stage in the operation, be dissected up from the 
bone and turned down, while pressure is at the same time made by the fingers 
of an assistant upon the facial artery where it passes over the lower jaw. 
Several arterial branches in the flap will require the ligature, after which the 
soft parts are to be dissected away from the nasal process, and also the carti- 
lage of the nose from the nasal notch of the maxilla. 
Second stage.-After extracting the middle incisor tooth of the affected 
side, the malar bone should be severed close to its junction with the maxilla. 
This can be most conveniently done by the large bone pliers. If any diffi- 
culty is experienced, let the division be partially made with the saw and 
completed with the bone pliers. After effecting the disjunction of these 
pieces, a similar division of the nasal process is to be made, when the disease 
will admit, just below the groove in which lies the lachrymal sac. Two 
incisions are to be made ovei' the hard palate, one posterior and transverse, 
separating the soft palate from the palatine bone, and the other extending 
from the inner extremity of the first along the longitudinal suture uniting 
the horizontal plates of the palate bones and the upper maxillae to the alve- 
olus from which the incisor tooth was extracted. The hard palate is now to 
be divided; and this can be accomplished either by the large straight pliers, 
one blade being introduced through the nose and the other through the 
mouth, or by inserting the saw through the nose and sawing through the 
plates of bones from behind forward. This is preferable, as it causes no com- 
minution. In executing this part of the operation the saw follows the incision 
made through the soft tissues of the hard palate, and must not trench on the 
suture, the edges of which support the bony septum of the nose. 
Third stage.-It only remains now to dislodge the bone from its bed and 
Fig. 1645. 
Incisions for removing the upper maxilla. 972 
SURGICAL DISEASES OF THE MOUTH. 
from the pterygoid process of the sphenoid, against which it rests. After 
detaching the periosteum from the orbital plate of the maxilla with the 
handle of the scalpel, or with an elevator, and thus leaving a support for the 
ball of the eye, the surgeon seizes the jaw with his fingers, or, in the case 
of a tumor, with the lion for- 
ceps, and draws it strongly 
outward and downward, 
separating with the finger 
or with a blunt-pointed bis- 
toury or scissors any re- 
maining connections which 
the bone may have with 
the soft parts. (Fig. 1646.) 
Frequently it will be found 
that the disease does not 
implicate the orbital plate 
of the bone; and when this 
is the case the latter should 
by all means be left. This 
is done, after dividing the 
nasal process, by introduc- 
ing the saw into the opening 
and cutting the body of the 
bone away from the floor of 
the orbit by sawing along 
the infraorbital ridge to the 
malar suture. 
Fourth stage.-Any hemorrhage which follows must now be attended to; 
but, if the operator has been careful, it is rarely necessary to apply more, 
perhaps, than one or two ligatures. I have, however, seen very profuse, even 
alarming, bleeding in the extirpation of the upper jaw. To avoid this, keep 
close to the tumor while the latter is being uncovered, and, after this is 
accomplished, attack the bone as far from the growth as possible. 
In one case, that of Hewett, death was attributed to the blood flowing 
into the air-passages,- a doubtful explanation of the unfavorable result. 
In view of such a possibility, the operation of tracheotomy has been sug- 
gested as a preliminary measure to the excision. If the patient is allowed 
to come partially from under the anesthetic, while the deeper connections of 
the jaw are being separated, and the mop is frequently used, no danger from 
this source need be apprehended. The ligature of the carotid artery as a 
preliminary measure, once practiced by Lizars, is not deemed necessary at 
present, and very rarely indeed is a resort to the hot iron required. The flap 
is now to be replaced, and stitched with the interrupted suture, introducing 
a single twisted one at the free border of the lip. A piece of lint moistened 
with carbolic acid and olive oil is next to be laid over the wound and kept 
in position by a light compress and a few strips of adhesive plaster. The 
mouth will require to be frequently washed out with warm water or chamo- 
mile tea, in order to remove the vitiated secretions. Union usually follows 
very quickly. The twisted suture can be removed about the third day, and 
the others about the fourth or the fifth day. The diet for the first four 
days ought to be restricted exclusively to milk, after which animal broths 
may be allowed. Should the face become much swollen, or assume an ery- 
sipelatous appearance, it should be treated by lotions of lead-watei* and 
laudanum. 
Excision of both upper maxilice was partially performed by Rogers, of New 
York, in 1824, but the entire removal of both bones was first executed by 
Heyfelder, in 1844. This operation does not differ in its details from that 
necessary for the removal of a single maxilla, except in requiring that the 
preliminary excisions for exposing the bones shall be made on both sides of 
Fig. 1646. 
Excision of the upper maxilla-the appropriate instruments applied 
to the parts requiring division. RESECTION OF THE LOWER JAW. 
973 
the face. The operation has now been reported ten times, including that of 
the above-named surgeon. 
Partial excision of the upper maxilla.-When the disease is limited to the 
alveolar border of the bone, or when the orbital or palatine plates remain 
sound,-provided the disease is not malignant,-excision should be restricted 
to the affected part of the jaw, and may be carried into effect without 
dividing the cheek. 
For example, when only the lower part of the body of the maxilla is af- 
fected, the disease may be removed by separating the cheek from the bone, 
and excising the latter to the required extent with the straight and curved 
pliers. With equal facility, by detaching the lip and the alae of the nose, 
portions of the alveolus and palatine plates can be cut away. 
In one instance, I removed before the medical class of the hospital of the 
University the entire upper maxillary bone, except its orbital plate, with- 
out any external incision. Professor Horner, in a case of cancer of the 
antrum, excised the maxilla entire, all the incisions being made within the 
mouth. 
When the disease occupies the antrum, is benign, and of a nature demand- 
ing operation, no incision will answer better for exposing the part than one 
carried from the angle of the mouth to the zygoma, beginning at the upper 
border of the first, or one made along the anterior border of the masseter, 
stopping short of the duct of Steno, and a second along the lower border of 
the orbit, the two joining immediately behind the malar bone. In all cases 
of malignant disease of the upper maxillary bone, when an operation is de- 
termined upon, partial excisions are useless, the entire maxillary requiring 
to be removed; and even when this radical measure is adopted the recurrence 
of the disease may be anticipated. 
Secondary hemorrhage has in a very few instances followed excision of 
the upper maxilla, as in a case under the care of Dr. Pancoast, in which 
the carotid was successfully tied. A similar case occurred to Mr. Wagstaffe, 
requiring the ligature of the primitive carotid, notwithstanding which the 
patient died. 
The deformity which follows even complete excision of the upper jaw is 
by no means conspicuous, the void being tilled up to a considerable degree 
with a formation of dense connective tissue. 
When the tumor is malignant, and returns after excision, secondary oper- 
ations are useless. They can do no good, as it is impossible to follow the dis- 
ease into the different recesses and sinuosities which are in communication 
with the jaw. 
In 36 operations of removal of the upper maxilla, including partial and com- 
plete excision of one or of both bones, which include the cases of Hutchinson, 
Esmarch, Braun, and Heyfelder, there were 85 relapses and deaths, 212 re- 
coveries, and 64 terminations unknown. Classifying the excisions on the 
basis of the amount of bone removed, Hutchinson gives 17 cases of complete 
excision of the maxilla, with 14 recoveries; Esmarch, 10 cases, with 8 
recoveries; Heyfelder, 141 cases, with 51 recoveries, 33 relapses, and 57 
unknown; Braun, 11 cases, with 7 recoveries and 4 unknown. 
Of partial excisions of one maxilla, Heyfelder has collected 153 cases, 48 
of which were cured, 35 relapsed or died, and 70 were undetermined. The 
same surgeon has analyzed 11 cases of complete and 8 of partial excision 
of both maxillae, 5 of the former class being cured and 6 relapsing or dying; 
in the last or partial class, 7 were cured, 1 relapsing and dying. Braun fur- 
nishes also the result of 5 cases of partial or consecutive excisions of the 
jaw for tumor and 7 for necrosis, all of the former recovering, and 6 of the 
latter. 
Analyzing the cases collected by Hunter, I find that in 158 excisions of 
all kinds of the upper jaw, 128 recovered, 27 died, and 3 relapsed. In 12 
instances in which the excision of both maxillae was complete, 8 recovered, 
3 died, and 1 relapsed; in 120 removals of one upper maxilla, 99 recovered 974 
SURGICAL DISEASES OF THE MOUTH. 
and 21 died; and of 24 partial excisions of the upper jaw, 20 recovered, 1 
died, and 3 relapsed. As far as it was possible to follow out the history of 
those reported recovered after excision of both jaws, the disease recurred in 
one case after the lapse of one year, in a second after five months, and in a 
third after three months. In one which was seen a year after the operation, 
no return of the disease was noticed. The diseases for which the excisions 
were done were-carcinoma, 6; sarcoma, 3; fibroma, 1; and phosphor-necrosis 
and necrosis, each 1. 
Of the 99 recoveries after removal of one upper jaw, 14 were known to 
have relapsed. The diseases for which the excisions were performed were 
for the most part sarcoma, carcinoma, and fibroma. 
Post-Maxillary Tumors.-In examining the articulated skull, a space will 
be seen behind the tuberosity of the superior maxilla, between the latter, 
and the great wing and the pterygoid process of the sphenoid bone (spheno- 
maxillary fossa). This space communicates with the temporal region, with 
the facial region, with the orbit through the spheno-orbital fissure, and with 
the palate, pharynx, and posterior nares. Tumors may take their origin in 
the spheno-maxillary fossa, springing from any portion of its boundaries, and 
develop finally into any of the regions in communication with this space. 
The connections of the pterygoid fossa offer an obstacle to the extension of a 
growth in this situation downward into the neck. The secluded location of 
morbid growths in this fossa allows of their making considerable progress 
before being discovered. Some exceedingly ingenious osteoplastic opera- 
tions for the extirpation of these tumors have been devised by Langenbeck, 
who has given to them much careful study. 
The spheno-maxillary region can be entered by making one longitudinal 
incision along the lower border of the zygoma, commencing three-quarters 
of an inch in front of the ear, and terminating at the middle of the infra- 
orbital ridge; and another vertical incision, beginning on a line with the 
posterior part of the malar prominence, and extending from the first incision 
down to the level of the duct of Steno. The flaps are to be dissected and 
turned in opposite directions, when the origin of the masseter muscle and 
the zygomatic arch will be brought into view. The muscle is now to be 
detached from the latter and the malar bone, and turned down, after which, 
if the growth is of a nature requiring more room for its removal, the ante- 
rior portion of the zygomatic arch and the coronoid process of the inferior 
maxilla may be cut away. 
Watson, of Edinburgh, entered the pterygo-maxillary fossa, and removed, 
successfully, a fibroma, by making an incision along the base of the inferior 
maxillary from behind its angle to the symphysis, and from thence through 
the middle of the lip, afterwards dividing the jaw and drawing it sufficiently 
to one side to give access to the pterygoid space. After the removal of the 
tumor, the ends of the jaw were united with wire. 
Excision of growths which have entered the pharynx or the nasal fossa 
from this region will be considered with affections of the nose. 
The cleft left in the hard or the soft palate from failure in the two sides to 
coalesce is generally a congenital defect, and is often associated with hare- 
lip, and occasionally with perforation, though both are seen as a result of 
syphilitic ulceration and necrosis. Various degrees of the defect are met 
with. The simplest is a slight notch extending a little distance into the 
median line of the uvula ; or the cleft may extend to the palate bone through 
the soft palate; or through the palate to the horizontal plates of the maxilla; 
or between the latter to the alveolus; or even through the alveolar process, 
either as a single fissure or a double V-shaped one, the intermaxillary bone 
being placed between the two branches of the V. 
Cleft Palate. CLEFT PALATE. 
975 
Not only have we all degrees in the antcro-posterior extent of the cleft, 
but also in the width of the gap between its sides, which varies from a slight 
fissure to a chasm, and which may even practically bring the two cavities- 
oral and nasal-into one. 
Treatment.-As cleft palate is often associated with hare-lip, it will be 
proper to close the latter before attempting more. If successful in this, the 
tension which results from the united lip will in a short time materially di- 
minish the palatine fissure, and contribute to the success of an operation for 
its subsequent closure. 
With regard to the proper age for making an attempt to close a cleft of 
the hard or soft palate, I do not believe that it can be undertaken with any 
encouraging prospect of success earlier than from the third to the fifth year. 
I have operated at all periods, from infancy to twenty-five years of age, and 
have learned by experience to avoid very early operations. While it is true 
that by the use of anaesthetics one of the great difficulties in the closure 
of palatine clefts has been removed, this does not obviate the evils w'hich 
result from the want of vital resistance in the tissues concerned, the fretful- 
ness, and the indisposition to swallow food, which may be expected in very 
young children who have been the subjects of this operation. I am not, 
however, in favor of waiting until puberty, as has sometimes been advised, 
before undertaking the operation. A delay of this duration only increases 
the defect in articulation, which persists in some degree even after successful 
closure of the cleft. 
Nor must the general health be overlooked in estimating the probabilities 
of securing union in the parts. Staphylorrapby, more than any other op- 
eration, demands for its success an entire freedom from indisposition, and to 
attempt the treatment in defiance of this precaution is to subject the patient 
to a hopeless surgical procedure. 
History of staphylorraphy.-The operation for the cure of cleft palate by 
paring the edges of the cleft was first proposed by Le Monier, a French 
dentist, in 1764; but it was not until 1819 that any practical advance was 
made towards the realization of the desired object, when Roux, the cele- 
brated French surgeon, not only succeeded in effecting the first cure by surgi- 
cal operation, but also formulated the rules for its performance. Nearly about 
the same time,-in 1820,-and altogether independent of Roux, Warren, of 
Boston, brought to the notice of the profession a similar operation, which in 
facility of execution was preferable to that of the French surgeon. These 
operations were followed in this country by those of Stevens, of New York, 
Mettauer, of Virginia, Wells, of South Carolina, Gibson, of the University 
of Pennsylvania, Ilossack, the younger Warren, Mutter, and Pancoast; and 
on the Continent and in Great Britain by those of Graefe, Dieffenbach, Sedil- 
lot, Liston, Fergusson, and Pollock. In 1844, Fergusson made a very impor- 
tant improvement in the operation,-that of relieving the tension on the 
ligatures by the formal division of the levator palati, palato-pharyngeus, and 
palato-glossus muscles on either side. The division of the pillars of the 
fauces as a means conducing to union was not unknown even before the 
operation of Fergusson, as it had been suggested by Mettauer as early as 
1837, and performed by the younger Warren in 1843. 
As the tension of the palate is dependent in a large measure on the con- 
traction of the circumflexus palati, a very marked relaxation will follow the 
division of the tendons of the muscle where they pass round the hamular 
processes of the sphenoid bone. This particular tenotomy I performed as 
early as 1860, in a young lady whose palate I closed with the assistance 
of Dr. Brinton, of this city; and I attributed the success of the operation 
to this procedure. The division was accomplished by carrying a narrow- 
bladed tenotome along the posterior termination of the alveolar process and 
the extremity of the outward plate of the pterygoid process of the sphenoid 
bone, and cutting directly upon the tendon of the circumflex muscle behind 
the hamular process. The late Mr. Pollock, of London, recommended the 976 
SURGICAL DISEASES OF THE MOUTH. 
same procedure, differing only in the direction of his incision, which was 
made on the inner side of the hamular process after carrying the knife 
through the soft palate. 
Operation.-The operation of staphylorraphy on a person who has ar- 
rived at an age when the surgeon can secure the co-operation of the patient, 
though a tedious one, is not a difficult one, nor is it attended with sufficient 
pain to make it necessary to use an anaesthetic. The fauces, however, should 
be handled with a spatula frequently for a few days before the operation, in 
order to render the parts tolerant of the manipulations attending the closure. 
In young subjects nothing can be done without the use of an anaesthetic. 
Quite a number of complicated contrivances have been devised from time 
to time for the performance of staphylorraphy, but in this, as in all other 
surgical procedures, the tendency to instrumental simplification increases 
with experience. The instruments which I employ are a gag, to keep the 
mouth open ; a long pair of rat-toothed forceps, to hold the palate (Fig. 
1647); a delicate, keen, double-edged scalpel with a long handle, to pare the 
Fig. 1647. 
Forceps. 
edges of the cleft (Fig. 1648); two needles, standing at an angle with the 
handle, and having the eye near the point (Fig. 1649) ; a small hook, to dis- 
Fig. 1648. 
Scalpel. 
engage the loose thread from the eye of the needle; a pair of ordinary scis- 
sors ; an adjuster (Fig. 1650), to tighten the wires and thus bring the freshened 
Fig. 1649. 
sides of the chasm together; some fine silver wire for sutures; a few perforated 
shot; and a compressor, with which to clamp the sutures. 
Needles. 
Fig. 1650. 
Adjuster. 
There are several forms of the gag, but the simplest is that figured on 
page 914. Indeed, the mouth can be kept open very well with a piece of 
cork having a cord attached and slipped in between the back molars. Only 
when the patient is a child is it necessary to use an instrument of the kind. 
The operation may be divided into three stages,-namely, freshening the 
sides of the cleft, passing the sutures and dividing the muscles of the palate, 
and closing the wound. CLEFT PALATE. 
977 
The patient being etherized, and, if a child, placed in a semi-recumbent 
position, the jaws are to be opened with a gag. The surgeon now, taking his 
stand either behind or in front of the patient, as he finds most convenient, 
seizes with the forceps the extremity of the uvula on one side of the fissure, 
puts it upon the stretch, and then, transfixing it with the knife, pares away 
one side, cutting first upward and then downward, so as to remove from the 
fissure a thin strip of tissue, leaving a raw surface from the base to the apex 
of the cleft, after which the opposite side 
is to be treated in a similar manner. (Fig. 
1651.) 
The sutures, beginning above, should 
be about three-sixteenths of an inch 
apart, and, in order that they may not 
cut out prematurely, will require to be 
passed about a quarter of an inch from 
the borders of the fissure. In order that 
the silver thread can be readily detached 
from the needle, it should, after passing 
the eye of the instrument, be bent into a 
short hook. 
The introduction of the threads is 
effected by passing the needle through 
the palate on one side of the cleft from 
before backward, and through the op- 
posite side from behind forward. The 
passage is facilitated by stretching at the 
same time the parts with the forceps. 
As soon as the point of the needle appears in front, the wire is disengaged 
from its eye with the hook and drawn through, after which the needle is 
withdrawn. (Fig. 1651.) After trying different plans for accomplishing this 
very difficult part of the operation, I find the above to be the easiest of 
execution. 
As soon as the suture is in position, its two ends are to be twisted together 
and bent upon themselves, so as to retain them temporarily together. After 
all the stitches have been introduced, their ends are to be untwisted, and 
pressed, one suture at a time, through the opening in the adjuster. As the 
latter instrument is forced down upon them, the sides of the cleft are brought 
together and so held by the set given to the wire. Each separate suture is 
subjected to the same process, after which the ends are passed through a 
perforated shot, which is now forced down in contact with the line of approx- 
imation, and clamped with the compressor in the order in which the stitches 
were inserted,-that is, from above downward. To complete this stage of 
the operation, it remains to relieve muscular tension by the division of the 
anterior and posterior lateral half-arches. 
When the space between the sides of the cleft is not great, and the tissues 
not scant, the myotomy may be withheld until the sutures have been inserted 
and permanently clamped ; but when the reverse is the case, the division of 
the muscles must be made as soon as the edges of the fissure have been 
freshened. Fergusson's plan, to which reference has been made, was to pass 
a sickle-shaped knife through the cleft, near its apex, and, turning the point 
of the instrument against the posterior surface of the palate, cut directly 
downward, with a view to divide the levator palati, afterwards cutting 
through the palato-pharyngeus muscle. The levator palati is much less at 
fault than the eircumflexus palati muscle, though the cut which divides the 
first will also sever the fibres of the last. 
In most instances it will only be required to sever the anterior and pos- 
terior arches, which is most conveniently done by putting them on the 
stretch with a pair of forceps and dividing them transversely with curved 
scissors, opposite to the tonsils. 
Fig. 1651. 
Paring edges of cleft and introducing sutures. 
vol. ii.-G2 978 
SURGICAL DISEASES OF THE MOUTH. 
When it is desirable to cut the circumflexus palati, palato-pbaryngeus, and 
palato-glossus muscles, it may be effected by transfixing the velum above the 
point where it is joined by the arches, and cutting downward and outward, 
stopping short of the crescentic edges of the two pillars. (Fig. 1652.) W hat- 
ever operation is adopted, the division must be 
made on both sides alike. 
After-treatment.-The patient, after the oper- 
ation, should remain quiet, avoiding all those 
movements which tend to disturb the parts, as 
laughing, yawning, and talking. The nourish- 
ment, consisting wholly of milk, beef-essence, 
and eggs, should be taken freely, in order to 
maintain the general strength of the system 
and thus conduce to the rapid healing of the 
wounds, while the secretions of the mouth and 
pharynx which adhere tenaciously to the palate 
are to be removed daily with a large camel's- 
liair brush. At the expiration of the eighth or 
ninth day the sutures may be removed by clip- 
ping out the wires in the reverse order of their 
insertion. 
Complications.-When the fissure extends a 
short distance through that portion of the longi- 
tudinal palatine suture formed by the horizontal 
plates of the palate bones, it will be impossible to bring the edges at the upper 
angle of the soft palate in contact without detaching the latter from the 
palate bones. This can be done by means of a little instrument (Fig. 1653) 
Fig. 1652. 
Showing sutures clamped, and the di- 
vision of the arches, the circumflexus 
palati, and the levator palati. 
Fig. 1653. 
Instruments for raising the soft tissues from the hard palate-two patterns. 
which, being passed behind the velum and applied between the latter and the 
bone, will enable the operator to make the necessary separation, after which 
the edges, being freshened, may be brought together by suture. 
If union fails at the upper angle of the wound, and a small opening re- 
mains, it may subsequently be closed by granulation ; but to effect this it 
will be necessary to stimulate an abundant growth of granulation tissue 
by frequently touching the borders of the opening with tincture of iodine 
applied with a camel's-bair brush. 
Affections of the Hard Palate. 
Hypertrophy of the transverse ridges or bars at the anterior part of the 
hard palate may occur from contusions of the mucous membrane. The 
swelling resembles in some respects the disease which in horses is termed by 
farriers the "lampers." The thickening, should it not disappear spontane- 
ously, can be removed by occasionally touching the bars with tincture of 
iodine. 
Abscess of the hard palate is likely to follow contusion of the mucous 
membrane, and, less frequently, a misplaced tooth. The soft, fluctuating, 
and pointed character of the swelling will reveal the nature of the enlarge- 
ment, the contents of which should be evacuated at as early a period as pos- 
sible, to prevent separation of the soft tissue overlying the bone. AFFECTIONS OF THE HARD PALATE. 
979 
Vascular Tumors of the hard palate are exceptionally rare. They may be 
either erectile or aneurismal. Professor Gross mentions one of the latter kind 
which arose from a wound of the posterior palatine artery, and which was 
cured by laying open the tumor and tying the distal and proximal ends of 
the vessel. 
Erectile tumors will resemble in appearance the angeiomatous growths of 
the gums or jaws already described. When small, and not growing, they 
may be allowed to remain without interference; if, on the contrary, a steady 
increase is observed, and the disease is circumscribed, excision and the actual 
cautery will be required. When the vascular growth is chiefly arterial, 
which may be determined by its florid color and its sudden distention under 
excitement, no operation should be undertaken which does not contemplate 
the excision of a portion of the jaw. 
Papilloma, encephaloma, sarcoma, and enchondroma of the hard palate, 
in their symptoms, characteristics, and treatment, differ in no respect from 
tumors of the kind situated in other portions of the jaw. 
Gangrene of the hard palate is a rare affection. It occurs only, so far as I 
know, in persons past middle life. The manifestations are unilateral, com- 
mencing in a livid discoloration of the mucous membrane at the posterior 
portion of the hard palate, near the angle of its junction with the alveolus, 
which advances forward and laterally, becoming gradually of a black color, 
and implicating both the gums and the other portions of the hard palate, but 
not transcending the limits of the palatine suture. The breath is stinking, 
being loaded with the gaseous products of decomposition. Almost immedi- 
ately on the appearance of the gangrene, general symptoms arise. The pulse 
is feeble and frequent; the tongue becomes dark, dry, and is streaked in the 
middle with a strip of red. There is extreme exhaustion, accompanied by 
sweats, nausea, wandering, subsultus, and hiccoughs, and ending in death. 
Two cases of the disease which I attended, one in consultation with Drs. 
Fischer and Da Costa, and the other with Dr. Dallam, terminated fatally, the 
first, I believe, on the fifth and the other on the sixth day from the com- 
mencement of the attack. In neither was there opportunity for an autopsy; 
but the cause of the gangrene was in both almost certainly an obstructive 
clot in the posterior palatine artery. 
The remedies employed in each of these cases were tonics, stimulants, milk, 
and animal broths, and at the same time disinfectant mouth-washes of per- 
manganate of potash, dilute alcohol, etc. 
Cleft in the Hard Palate.-Not unfrequently congenital clefts extend through 
the entire length of both the hard and the soft palate. This is an unfortunate 
defect, but in many instances is not beyond the pale of surgical treatment. 
Cases which should be excluded from operative measures are those in which 
the horizontal plates of the upper maxillary and palate bones remain in a 
rudimental state, scarcely projecting beyond the alveolus. Even this un- 
promising condition is only a temporary one, as subsequent development of 
these portions of the bone may take place. When the defect is conjoined 
with hare-lip, an early operation for the cure of the latter should be prac- 
ticed, as success in this respect will be followed by a marked diminution in 
the breadth of the cleft in the hard palate; if the fissure of the soft palate 
can be closed, even though only partially, the influence in lessening the 
chasm in the palatine suture will be still more marked. 
Uranoplasty.-The process of closing palatine clefts is technically termed 
uranoplasty,-an operation for which the profession is indebted to Dr. J. 
Mason Warren, of Boston. The method of Warren, which was published in 
1843, consisted in paring away the mucous membrane on each side of the 
cleft, and afterwards raising the same from the bones, as far outward as the 
alveolus, by means of a double-edged knife curved on the flat. After their 980 
SURGICAL DISEASES OF THE MOUTH. 
detachment, the flaps were slid over to the median line, and brought together 
by a number of interrupted sutures. Langenbeck, in performing this opera- 
tion, made his incisions close to and parallel with the alveolus, subsequently 
raising all the soft parts from the palatine plates, including the periosteum, 
with an elevator. This operation is supposed to have some advantages over 
that of Warren, as it is believed to endanger the vitality of the flaps less, 
including, as it does, all the soft tissues covering the bone; it also takes ad- 
vantage of the osteogenetic function of the periosteum, and may result in 
bridging the chasm with new bone. 
There is some force in the last observation, but not in the first, as the di- 
vision of the branches of the posterior palatine artery, and their separation 
from the flap when it is slid over in the direction of the fissure, increase 
the risks of sloughing,-an occurrence which has frequently defeated the suc- 
cess of the operation. Sir William Fergusson, in 1873, carried into practical 
operation a method which the ingenious Dieffenbach had suggested more than 
a quarter of a century before, that of cutting through the hard palate in its 
entirety, and, after moving the longitudinal sections into contact with each 
other, securing them together by silk sutures. His plan of carrying into 
effect this procedure is as follows. The edges of the fissure in both the bard 
and the soft palate are first pared. With a brad-awl two or more perfora- 
tions are next made through the hard palate on each side of the cleft, about 
one-eighth of an inch from its borders, and directly opposite each other. 
Through these openings threads are passed and loosely secured. An incision 
is next made on each side down to the bone, close to the alveolus, and through 
the whole longitudinal extent of the hard palate. Along these incisions 
the bone is divided by means of a chisel, after which, by tightening and tying 
the ligatures, the two sides of the cleft are brought into contact. This part 
of the process is much more conveniently executed by means of a silver 
wire in place of thread and the soft clamp. (Fig. 1654.) In order to pre- 
vent comminution, Mason, in 1874,* suggested per- 
forating the bone at several points in the course 
of the lateral incisions before applying the chisel. 
This will tend to diminish the risks of necrosis. 
After the palatine plates have been adjusted and 
permanently fixed by the stitches, the operator 
introduces and secures the sutures of the soft 
palate; or, if the patient is too much exhausted, 
the closure of this part of the cleft may be left for 
another operation. The hemorrhage from the 
division of the posterior palatine vessels is quite 
free, and should be checked by introducing nar- 
row pledgets of lint into the lateral cuts. 
Should the palatine process be attached to the 
vomer on one side, as is sometimes the case, it 
must be separated by the knife or chisel as a pre- 
liminary step to the operation; otherwise the fresh- 
ening of the cleft on that side cannot be done, nor 
can the two palatine processes be reduced to the same level for the purpose 
of adjustment. 
The same rules in reference to quiet and nourishment are to be observed 
after these operations on the hard palate as after those performed on the 
velum. The pledgets of lint introduced to control bleeding may be removed 
in about forty-eight hours, and the sutures in the course of from four to six 
days, depending altogether on the firmness of the hold and the absence of 
all undue irritation. 
The adoption of any particular operation in these cases must be determined 
by the individual peculiarities. When only of moderate extent and with 
thick soft parts overlying the hard palate, Warren's operation is to be pre- 
Fig. 1654. 
Fergusson's method of closing a pal- 
atine cleft by osteotomy. 
* Surgery of the Face, p. 107. AFFECTIONS OF THE FAUCES. 
981 
ferred ; but when the chasm is large and the mucous and submucous tissues 
are thin, the method of Fergusson is preferable. It is also important to say 
that in very narrow fissures of the hard palate, pressing the jaws frequently 
towards each other will finally bring the sides of the cleft together without 
a resort to the knife; and the same result is favored by a successful closure 
of the gap in the soft palate. 
Another operation-one recommended and successfully practiced by Dr. 
Garretson, of this city-consists in freshening the margins of the cleft, and 
then applying to the jaws a horseshoe-shaped clamp similar to that of 
Hainsby, and, by means of a screw, forcing the sides of the cleft together 
at once. This is entirely feasible in the young bone and when the fissure is 
narrow. The child should be etherized during the operation, and after the 
removal of the clamp, in ordei* to retain and perpetuate the advantages 
gained, two stout compresses are to be placed, one over each cheek, below 
the malar bone, and kept in position by means either of a rubber ring slipped 
over the head of the patient, or of a small hard-rubber truss, the spring 
resting on the top of the head, and the pads over the buccal compresses. 
Mechanical Treatment.-When unable to close a palatine cleft, either in 
consequence of indisposition on the part of the patient to submit to an opera- 
tion, or from intractable conditions connected with the defect, the evil can be 
greatly remedied by mechanical appliances, of which the best is the very 
ingenious one constructed by Dr. N. Kingsley, of New York. It is formed 
on a principle conceived by Mr. Stearn, of London. Dr. Kingsley exhibited 
this obturator to me shortly after he had succeeded in bringing it to a suc- 
cessful completion. It consists of a gold plate, moulded to fit the hard palate, 
and to which is attached, by springs, a flexible piece of rubber fashioned so 
as to fit the margins of the cleft, and also to imitate, in form and function, 
the soft palate and the arches of the fauces. 
Perforations of the soft and hard palate frequently occur as a result of 
syphilitic ulceration and necrosis. Those in the velum can be closed by vivi- 
fying the margins of the orifice with a bistoury, drawing the sides into con- 
tact by sutures, and, if necessary to relieve tension of the ligatures, making 
an incision into the palate on each side of the wound. 
When there exists a perforation in the hard palate, an obturator can be 
prepared which will not only prevent the intrusion of particles of food into 
the nose, but will also restore the natural tone of the voice and articulation. 
These obturators are constructed of gold or hard rubber by the dentist, 
and should never enter the perforation, otherwise its size will be increased. 
Affections of the Fauces. 
Elongation and Hypertrophy of the Uvula.-The uvula, particularly in 
patients subject to inflammation of the tonsils and arches, is frequently the 
subject of catarrhal disease, causing either oedema of the submucous con- 
nective tissue, or, when of a chronic nature, giving rise to plastic deposits 
which increase the bulk of the entire body of the parts. There is also an 
elongation or lowering of the uvula which is altogether independent of any 
inflammatory cause, being brought about either by general relaxation of the 
muscles of the velum from local or constitutional weakness, or by paralysis, 
as is often witnessed in diphtheria. 
When the elongation or the oedema is due to an acute attack of faucial in- 
flammation, the uvula presents an intensely red and swollen appearance in 
addition to its increased length,-often resting on the tongue,-and there is 
usually considerable soreness of the throat and more or less discomfort in 
swallowing. Frequently a little transparent bladder of mucous membrane 
will be seen below the muscular tissue of the body, dissected off from the 
latter by the serum, which gravitates to the most dependent part. The pa- 
tient experiences an irritation at the root of the tongue, and often complains 
of the constant inclination to swallow something. Hypertrophy of the uvula 982 
SURGICAL DISEASES OF THE MOUTH. 
may be readily recognized by the general enlargement as well as elongation, 
-the latter being the result of the former,-and by the dense fleshy con- 
sistence of its structure. 
Elongation merely from muscular relaxation can be distinguished from 
other forms of the affection by the natural shape of the uvula and by the 
diminished size of the isthmus of the fauces. 
Paralytic elongation, whether from diphtheria or from cerebral compres- 
sion, is associated with a similar state of the velum and arches, occasions a 
snoring or stertorous noise in sleep, and allows fluids to regurgitate through 
the nose when deglutition is attempted. 
The evils resulting from chronic elongation or dropping of the uvula are 
irritation and congestion of the fauces, which may finally extend to the larynx, 
and a worrying, hacking cough. 
Treatment.-Acute elongation of the uvula, such as commonly belongs to 
catarrhal attacks of the fauces during cold, damp, and changeable weather, 
and in good constitutions, generally yields in a few days to a cathartic, as- 
tringent gargles, and an anodyne at night. When it manifests a disposition 
to linger after the other symptoms have disappeared, a ten-grain solution 
of nitrate of silver, applied with a camel's-hair brush once or twice a day, 
will generally effect in a short time the reduction of any undue fullness of its 
vessels, and secure the absorption of whatevei' inflammatory products may 
remain. 
Hypertrophy of the uvula may be reduced by an application of the com- 
pound solution of iodine once every second day to the parts; this should be 
continued foi* several weeks, unless they become sore, when it may be sus- 
pended until the inflammation subsides, and then be resumed. 
General relaxation of the muscles of the velum, uvula, and arches must be 
treated by tonics, to which strychnia is a valuable addition, by electricity, 
and by employing all general agencies capable of invigorating the constitu- 
tion, as fresh air, wholesome food, sea-bathing, etc. 
Relaxation and elongation of the uvula and palate caused by diphtheria 
or cerebral paralysis can only be remedied in the former disease by tonics 
and time, eliminating the poison from the blood, and rendering that fluid 
suitable for the nourishment of the nerve-centres, and in the latter by 
removing the cause of brain-pressure. 
Removal of the uvula.-The structural alterations which follow inflamma- 
tory attacks frequently repeated render it necessary in many cases to excise 
a portion of the uvula. 
The operation is simple, and attended 
with no inconvenience whatever. Even 
the entire uvula may be taken away 
without interfering in the least with 
the voice or the functions of the palate. 
Such a mutilation, however, is never 
demanded, and would therefore be an 
unnecessary sacrifice of tissue. 
If the elongation is oedematous, it 
will only be required to strip off the 
little sac of mucous membrane at the 
tip of the uvula to effect a cure. But 
when arising from thickening, or from 
a combination of both the latter and 
infiltration, it will be necessary to re- 
move from a quarter to one-third of the 
process. 
Excision is accomplished in a few 
seconds by seizing the extremity of the 
uvula with a pair of long rat-toothed forceps, putting it on the stretch, and 
severing by a single stroke with the scissors the amount necessary to be 
Fig. 1655. 
Excision of the uvula. AFFECTIONS OF THE VELUM PALATI. 
983 
removed. (Fig. 1655.) The after-treatment is very simple, requiring only 
the use of a gargle of alum-water. 
Inflammation of the soft palate presents the same general appearance as that 
of the uvula and arches, to which allusion has already been made, is induced 
by the same causes,-generally catarrhal,-and demands the same treatment. 
Affections of the Velum Palati. 
Wounds of the velum are sometimes produced by sharp-pointed sticks, 
which, while being held between the teeth, have been forcibly driven into 
the mouth by an accidental fall. Gunshot wounds of the soft palate are 
sometimes inflicted by firing into the mouth in attempts at self-destruction, 
and also are among the possible contingencies of war. I have never seen 
an accidental incised wound of the velum. An injury of the character first 
named, which would be a lacerated wound, will, unless very extensive, heal 
without surgical interference, requiring only the use of astringent washes, 
applied with a large camel's-hair brush, to allay the inflammatory irritation ; 
while those caused by fire-arms will necessarily slough, followed by an in- 
creased loss of substance, which subsequent granulation cannot wholly re- 
pair, and which may require an operation to close. Incised wounds may also 
be left to natural processes, with the prospect of the opening being finally 
united by granulations. If, however, the division is extensive, and in a di- 
rection which is followed by much gaping, it should be sutured, as in a case 
of cleft palate, the after-treatment being also the same. 
Ulceration of the soft palate is rarely witnessed except as the result of 
syphilitic disease. The ulcers are often preceded by a patch of dark-red or 
purple inflammatory discoloration, which is soon followed by a superficial 
break in the mucous membrane, and, finally, by the formation of an un- 
healthy ulcer, incrusted with a gray layer of necrosed connective tissue. 
The destructive process often advances with such rapidity that in a few 
days the palate is completely perforated. 
The diagnosis of such a sore is not a matter of any difficulty. On inquiry 
there will be discovered other manifestations of constitutional syphilis. 
Treatment.-Treatment, when promptly and boldly adopted, will in most 
cases change the specific character of the sore, converting it into a healthy 
ulcer, which soon undergoes repair. The iodide of potassium is our sheet- 
anchor in a case of this kind. Mercury is too slow. The salt must be given 
in five-grain doses, largely diluted, every three hours, until the morbid action 
is arrested and the ulcer commences to heal, when the intervals of adminis- 
tration can be increased in length. I much prefer this plan to that of giving 
large doses at distant intervals. 
Gummata are less common on the soft than on the hard palate. They com- 
mence as oblong, painless, and doughy swellings, are tardy in their progress, 
and are never present independent of a syphilitic history. 
The treatment is the same as that employed for ulceration. 
Abscess of the soft palate is an exceedingly rare affection. A soft acumi- 
nated swelling, having a purple-yellow color, would be a sign of a purulent 
collection, and its treatment would not differ from that proper for an acute 
abscess in other localities, namely, the use of heat and moisture, which, in 
this situation, will be best applied by the vapor of hot water drawn into the 
throat; as soon as the evidences of pus are established, the abscess should 
be evacuated with a bistoury. 
Tumors.-The abundance of glandular tissue in the structure of the soft 
palate will explain the occasional development of an adenoid tumor in this 984 
SURGICAL DISEASES OF THE MOUTH. 
situation. It is most commonly met with in young people with strumous 
organizations; is oval in figure, sharply or abruptly defined at its circumfer- 
ence ; is elastic to the touch, and painless. (Fig. 1656.) The growth might 
be confounded with a cyst or a gumma. A 
cyst, however, is spherical, salient, and semi- 
transparent; and a gumma, being associated 
with other evidences of syphilis, is not seen at 
so early an age as the adenoid tumor. 
These growths, by their volume, may inter- 
fere with deglutition. The remedy is excision. 
In cases of adenotic hypertrophy of the post- 
nasal and palatine regions, as in old cases of 
catarrh, the entire soft palate may undergo a 
general thickening from a participation of its 
glandular element in the disease. This thick- 
ening, while primarily limited to the glands, 
ultimately extends, involving the entire velum 
by an inflammatory infiltration through all its 
tissues. 
The local treatment of such a condition must 
begin in the regions above and behind the soft 
palate,-to be hereafter described in connection 
with diseases of the nose,-by the application of nitrate of silver, solutions of 
iodine, chromic acid, and accompanied with the alternate internal use of 
Lugol's solution, iodide of iron, Donovan's solution, and cod-liver oil. 
Fig. 1656. 
Adenoid tumor of the velum. 
Cysts of the soft palate may occur in connection with, or independent of, 
an adenoma. They are round, tense, often slightly yellow, elastic growths, 
with walls which in time become so attenuated as almost to disclose their 
contents. They vary in size from a pea to a cherry. The fluid which they 
contain is either a glairy mucus, like the white of an egg, or a straw-colored 
liquid, sometimes thin, at other times almost gelatinous in consistence. 
These tumors are to be excised, and if a portion of the sac is allowed to 
remain, it must be treated either with the compound solution of iodine or 
with the solid nitrate of silver. 
Carcinoma of the soft palate is, unfortunately, too common. Several times 
within the last few months have 1 had patients under my care, victims of 
this horrid disease. The form of cancer may be either epithelial or medul- 
lary. They can be distinguished from each other, especially at an early 
period, by appearance, progress, and accidents. Epithelial cancer appears, 
after ulceration begins, as an irregular-shaped sore, with jagged edges, 
showing no disposition to heal, progressing slowly but steadily, and not 
manifesting much tendency to bleed. Encephaloid carcinoma commences as 
a tumor, progresses rapidly, soon ulcerates, and fills the mouth with foul 
bleeding granulations, the secretions from which soon contaminate the fluids 
of the body and impress on the face the characteristic cachectic expression. 
The lymph glands beneath the jaw and the neck become involved more 
quickly in the encephaloid than in the epithelial form of the disease. Cancer 
often commences on the alveolus, the floor of the mouth, or the cheek, and 
extends to the arches and the soft palate. The disease is incurable, death 
taking place either in consequence of repeated hemorrhages, or from the 
exhaustion incident to general blood-infection. 
Hopeless as are these cases, much may be done by the surgeon to alleviate 
the suffering of the patient by directing that the mouth be frequently washed 
out with a decoction of rhus glabrum, with dilute alcohol, and, when there is 
much tendency to bleeding, with a mixture of Monsel's solution of iron with 
water, or a hot solution of alum and water. Pain must be relieved by opiates, 
and the strength supported by liquids rich in the elements of nutrition. AFFECTIONS OF THE TONSILS. 
985 
Fibroma.-Fibrous tumors of the soft palate, described as polypi, are occa- 
sionally seen. They have a firm consistence, with an attachment sometimes 
pedunculated, at other times more sessile, and require excision. 
Affections of the Tonsils. 
Foreign Bodies may become lodged in the recesses of the tonsils and excite 
considerable irritation, which is often referred to the top of the larynx. 
Among these may be mentioned pins, needles, tooth-picks, and fish-bones. 
To examine the fauces and tonsils, the patient should be placed before a 
proper light, with the mouth open, and without protruding the tongue, and 
should be requested to take a full inspiration. Or, if the parts are not too 
irritable, the tongue may be depressed so as to give a still more satisfactory 
view, using a spatula or a depressor. Resorting to a measure of this kind, 
any foreign body can be readily detected by the eye and extracted with an 
ordinary forceps. 
Hardened Secretions and Calculi.-The tonsil is allied in its histological 
elements to both the sebaceous and the lymph glands,-the sebaceous portion 
of the organ being superficial or faucial, the lymphatic being deep and cervi- 
cal. Frequently from errors of the digestive apparatus the follicles become 
blocked up with an inspissated secretion, consisting of fatty and earthy 
matters, together with epithelial detritus, the decomposition of which is a 
common source of an unpleasant breath. Chalky concretions, the so-called 
calculi of the gland, composed chiefly of phosphate and carbonate of lime, 
are also found imbedded in some of the recesses of the gland, the tendency 
of which is to excite irritation and inflammation of the tonsil. These con- 
ditions can be detected by the eye and the touch. To remove the cheesy 
masses of inspissated secretion will require pressure with the finger, aided 
by alkaline gargles, while the extraction of cretaceous calculi will be best 
effected by the forceps or the scoop. 
If the concretion is large, or if several are present, it may become necessary 
to open or excise the gland. 
Parasitic Cysts are among the very exceptional affections of the tonsils. 
Dupuytren once laid open a tonsil for what he supposed was an ulcer, but 
which proved to be a hydatid cyst; and Davaine, as recorded by Mackenzie, 
met with a similar case, in which the sac contained a trichocepbalus. 
Tonsillitis, or Quinsy.-Acute inflammation of the tonsils is most common 
in persons between the ages of twenty and thirty. In Philadelphia the 
disease prevails mostly during the winter months, and is generally caused by 
exposure in cold, wet, or damp weather. There are two well-recognized forms 
of tonsillitis, the superficial and the general, or the follicular and the paren- 
chymatous. 
Symptoms.-Follicular tonsillitis is generally ushered in with a chill, followed 
by fever, a high temperature, thirst, headache, and general malaise. These 
symptoms are quickly followed by stiffness and dryness of the throat, slight 
hoarseness, tenderness to pressure made behind the angle of the lower jaw, 
painful deglutition, a more or less nasal tone of voice, general stiffness of the 
neck, and a tough, stringy mucus constantly collecting in the fauces. 
In parenchymatous tonsillitis these symptoms are greatly intensified : the 
tonsils are much swollen, perhaps touching each other and obstructing the 
fauces; deglutition is almost impossible; the swelling extends to the arches 
and soft palate; the secretions, profuse, tenacious, and slightly yellow, keep 
the patient constantly hawking with a pharyngeal sound in order to dislodge 
the accumulations; while the neck, stiff and helpless, is held in a fixed posi- 
tion. Follicular tonsillitis rarely lasts beyond three or four days, and tends 986 
SURGICAL DISEASES OF THE MOUTH. 
to resolution, while the deep or parenchymatous form of the disease tends to 
suppuration. 
Treatment.-In the simple or follicular variety, in which the inflammation 
does not penetrate deeper than the sebaceous crypts of the glands, little is 
required beyond rest in-doors, a hot foot-bath, a gentle cathartic, with an 
astringent gargle, consisting of a decoction of the berries of therhus glabrum 
containing some chlorate of potash, or a similar preparation made from the 
bark of the pomegranate, or, finally, the old domestic gargle of sage tea, borax, 
and honey. These, with a Dover's powder at night and abstinence from 
food, will almost always suffice to induce a rapid resolution of the disease. 
In parenchymatous tonsillitis much depends on an early use of remedies. 
At the commencement of the attack, if the patient is strong and vigorous, 
leeches should be applied below and behind the angles of the jaws. Free 
scarification of the glands with a bistoury may also be practiced. The local 
abstraction of blood is always followed by marked relief. Next in impor- 
tance-some will say first in importance-is the use of guaiacum. 
The value of this remedy admits of no question. It should be given in- 
ternally and also applied externally. Internally, it can be administered in 
the form of a lozenge, each containing three or four grains of the powdered 
gum, and one of them allowed to dissolve in the mouth every two or three 
hours, or it may be exhibited in the form of an emulsion, each teaspoonful 
representing a like number of grains. The local application of the drug will 
be best obtained by using the ammoniated tincture of guaiac, which may 
be added to one of the gargles already named. The patient may also be 
allowed the frequent use of small pieces of ice in the mouth. As the proper 
use of gargles in severe cases of quinsy is impossible, the local application of 
remedies can be made in other ways. Thus, a solution of nitrate of silver 
may be brushed over the swollen tonsils, or a solution of tannic acid, alum, 
or nitrate of silver can be addressed to the parts by either a steam or a band 
atomizer. The same substances can be applied by insufflation. A very good 
instrument for the purpose is that represented in Fig. 1657. The agent used 
is introduced into the tube, and driven from its cribriform extremity by press- 
ing the gum air-bulb at the other end of the instrument. 
Fig. 1G57. 
Insufflator. 
When these remedies fail, or when the disease has not been early combated, 
and it is apparent that suppuration will follow, the process should be encour- 
aged by applying hot flaxseed poultices about the throat, and directing the 
frequent inhalation of the vapor from hot water containing a little laudanum 
or chamomile tea. The simplest inhaler is an ordinary tin cup containing 
the hot liquid and covered by an inverted funnel, the steam being drawn 
through the neck. For the same object a rubber hose can be slipped over 
the spout of a teapot, and the vapor conducted through the tube into the 
throat. The physician should frequently examine the throat for the signs 
of pus, which may be detected sometimes by the eye, but more certainly by 
the conjoined pressure of two fingers, one on the swollen gland and the other 
beneath the angle of the jaw on the outside of the neck. As soon as a rigor 
or other symptoms announce the formation of pus, it should be liberated by 
puncturing the most prominent portion of the swelling with a sharp-pointed 
bistoury, and if successful in reaching the purulent collection the relief will AFFECTIONS OF THE TONSILS. 
987 
be instantaneous. In opening the abscess it must not be forgotten that the 
internal carotid artery lies at the base of the tonsil, and might easily be 
wounded if the point of the bistoury were allowed to penetrate the gland 
too far in the direction of the neck. The abscess, when it seeks the surface, 
points, as a rule, either anteriorly or internally. This, however, is not always 
the case; and the possibility of the pus taking a different direction should 
create a proper anxiety in the mind of the surgeon. 
A young student of medicine while attending the Jefferson Medical Col- 
lege was attacked with parenchymatous tonsillitis. He had been ill several 
days before I saw him. My visit was in the night, when I found him suffer- 
ing severely. An examination of the throat satisfied me that suppuration 
had occurred, and that the abscess was pointing posteriorly. I proposed to 
open the tonsil immediately; but, notwithstanding my representation of the 
danger of delay from the relation of the larynx to the abscess, he declined to 
have the incision made, preferring to wait until the morning. I left the 
house, but had not gone two squares, when he suddenly sprang out of the 
bed, fell on the floor, and expired in a few moments. The sac had burst and 
poured its contents into the windpipe, destroying bis life by suffocation. 
When the pus is deeply situated, if not liberated, it may travel into the 
neck. Roche mentions a case of this kind in which the abscess followed the 
course of the cervical vessels into the thorax, and Mailer and Norton each 
one in which the coats of the carotid vessels became eroded by the abscess 
and the patients died from hemorrhage. 
Hypertrophy, or enlargement of the tonsils, is an exceedingly common 
affection. W bile occasionally seen as the result of repeated attacks of quinsy, 
it is in most instances only one of the evidences of a strumous state of the 
general system. The enlargement is most common between the ages of 
five and ten, though it may be congenital. Cases of this hypertrophy 
among adults are only examples of a condition which began before pu- 
berty. Males are somewhat more liable to suffer from this disease than 
females. Frequently the subjects of this enlargement present other evidences 
of a constitutional vice, as tarsal ophthalmia, catarrh of the nasal mucous 
membrane, or eczema of the scalp. Not unfrequently the hypertrophy is 
traceable to an attack of measles or of scarlet fever. These affections, how- 
ever, are only the exciting, not the remote, cause of the disease, which, in- 
deed, is rarely encountered unconnected with a constitutional vice. 
Symptoms.-The signs of enlarged tonsils are sometimes so characteris- 
tically impressed on the face and voice of a child that the existence of the 
disease may be predicated on these alone, even before making an ocular in- 
spection of the throat. The eyebrows are drawn up, the mouth is open, the 
face lengthened, and the voice nasal. When the throat is examined, the 
glands are seen as conical or spherical bodies projecting into the isthmus of 
the fauces, beyond the free borders of the arches, and often almost touching 
each other in the middle line. These bodies, when enlarged, vary somewhat 
in appearance. While in some the surface is broken by a series of intersect- 
ing ridges, in others the most noticeable characteristic is the number of en- 
larged follicular recesses or cavities which exist. Their color is red, often 
with a tinge of blue. 
Evil effects.-The evils which attend typical cases of hypertrophied ton- 
sils are not a few. They extend to the respiratory, digestive, and nervous 
systems, and often to the organs of sense. As the glands enlarge, they inter- 
fere so much with the free passage of air from the posterior nares to the 
larynx that the patient is compelled to keep the mouth open, in order to 
offei' an additional route for the atmosphere to reach the lungs. For the 
same reason, breathing during sleep is labored, noisy, and snoring, so that 
the child rises in the morning dull, heavy, and unrefreshed, in consequence 
of the imperfect aeration of the blood in the lungs. Added to these evils 
is that of frequent attacks of tonsillitis, each one leaving an additional infil- 988 
SURGICAL DISEASES OF THE MOUTH. 
tration, which adds to the bulk of the gland. The hearing is also rendered 
dull, not from pressure of the enlarged tonsil on the Eustachian tube (which 
is anatomically impossible), but from the congestion and chronic inflammatory 
thickening of the tissues around its orifice. 
A change in the shape of the thorax has also been recognized among the 
alterations of structure accompanying this hypertrophy. This has been 
specially studied by Shaw and Lambron, its principal feature being found to 
be a constriction or narrowing of the walls of the thorax corresponding to 
the insertion of the diaphragm, and giving rise to one form of the " pigeon- 
breast." This is due to the increased activity of the diaphragm rendered 
necessary by the faucial obstruction to the entrance of air. It is not difficult, 
therefore, to understand why children who are the subjects of marked hy- 
pertrophy of the tonsils should be dull and spiritless, indisposed to romp and 
play with their companions, and unable to accumulate flesh and strength. 
Pathology.-The morbid condition consists in a hyperplasia of all the 
anatomical constituents of the healthy gland (Fig. 1658), connective tissue, 
mucous and lymph follicles, and blood-vessels. (Fig. 1659.) The structure 
of the tonsil may be tough and leathery in consistence, or quite friable, 
breaking down easily under the pressure of the fingers. Lodged in the 
recesses of the gland will often be found highly offensive cheesy casts or 
moulds of inspissated mucus, and also masses of cretaceous material. 
Fig. 1659. 
Fig. 1658. 
View of the interior structure of the healthy tonsil. 
Hypertrophied tonsil laid open. 
Treatment.-The treatment is topical, general, and operative. In many 
cases the size of the tonsils is so inconsiderable that no treatment of any 
kind is required. They may grow somewhat, or remain stationary, until 
after puberty, when they spontaneously diminish in size. In others, again, 
while they are not sufficiently large to give rise to difficulties of respiration 
and intonation, they are a constant source of irritation, and predispose the 
person to frequent attacks of sore throat, in which the glands participate. 
There are cases which can be greatly benefited by the systematic use of as- 
tringents, among which none have afforded me better results than powdered 
alum, or the compound solution of iodine, rendered as bland as possible by 
the addition of a little powdered loaf-sugar and gum acacia. The alum 
should be plastered over the tonsils, every night and morning, with a large 
camel's-hair brush well loaded with the powder. The iodine, when employed, 
can be brushed over the parts in the same way, once every second day. 
When the child is pale, thin, and without appetite, iodide of iron in pill form, 
cod-liver oil, and bathing will prove important adjuvants. 
Operative Measures.-However valuable as a palliative may be the treat- 
ment detailed, it can have little influence in reducing the hypertrophy of 
the gland; and when this is sufficiently great to occasion the evils which 
have been enumerated, nothing will avail but the removal of the redundant AFFECTIONS OF THE TONSILS. 
989 
portion of the tonsil. This can be effected in two ways,-by caustic and by 
excision. 
Caustic.-Many persons are indisposed to allow the use of the knife, and 
will foolishly permit their children to suffer rather than surrender their judg- 
ment to that of the medical attendant. Out of mercy to the child, it is better, 
under such circumstances, to submit to their prejudices and resort to caustics. 
Mackenzie is partial to the London caustic, which consists of caustic soda 
and quick-lime; and it certainly is the most manageable and altogether satis- 
factory member of the class. A little of the powder should be mixed with 
some water to the consistence of thick cream, and then applied by means 
of a wooden spatula to the tonsil at two or three points, and only to a very 
small portion of the surface at each. The patient should in three or four 
moments wash out the throat with a gargle of plain water, in order to re- 
move the redundant paste. A slough will follow the application at each 
point, and by repeated applications the tonsil may finally be very much 
reduced in size.* 
Donaldson, of Baltimore, effects the same end by making punctures or in- 
cisions into the gland and introducing for a few moments a crystal of chromic 
acid. The tonsil can be destroyed in the same way, and more quickly, by 
making two or three openings with a bistoury into its substance, and as soon 
as the bleeding subsides introducing a like number of arrows composed of 
the chloride of zinc. The action of this caustic is quite painful, and, it being 
deliquescent, the mouth and throat should be frequently washed out for the 
first twenty-four hours after its introduction. Injections of iodine, ergotin, 
and carbolic acid have also been practiced. 
Cohen, of Philadelphia, has succeeded in partially removing the hyper- 
trophy by electrolysis frequently repeated. The battery employed consisted 
of forty cells, and the application was by a long platinum needle, connected 
with the negative pole and inserted into the gland, while a sponge electrode, 
in connection with the positive pole of the battery, was applied over the 
neck, below the angle of the jaw. 
Excision.-The operation by excision is so simple, painless, and expeditious 
that, unless there is some cogent reason to the contrary, as, for example, a 
hemorrhagic diathesis, it should always be preferred. It was practiced in 
the time of Celsus, as also was avulsion with the fingers. Afterwards it 
seems to have fallen into desuetude, being alternately revived and con- 
demned, until 1740, when Richard Wiseman, among English surgeons, popu- 
larized the operation. Ligating the tonsils was resorted to by Sharp and 
Cheselden, sometimes by the single and at other times by the double 
ligature. 
The great dread in excision seems to have been hemorrhage: hence the 
precaution observed by Pare, Wiseman, and others, of encircling the gland 
with a ligature before excision with the bistoury. That this precaution was 
entirely unnecessary was afterwards shown by the French practice at the 
Hbtel-Dieu, Rheims, in 1757, when these glands were frequently and safely 
removed with the bistoury. Even as late as the time of Physick, who prac- 
ticed the method, strangulation with a canula and wire (the operation of 
Bebrach) was often employed in the removal of enlarged tonsils. 
Operation.-Excision of the tonsils can be accomplished by the vul- 
sellum forceps and bistoury, or by some of the various tonsillitomes. The 
operation must never be attempted when the glands are inflamed, otherwise 
a dangerous bleeding may tnsue, or possibly sloughing. 
If the knife is employed, the patient should be seated before a good light, 
and, while the mouth is wide open, and, if required, the tongue pressed down 
by an assistant, the surgeon seizes with a clean vulsellum the projecting por- 
tion of the tonsil, and, drawing the latter inward and forward, amputates, 
in a downward direction, with a curved probe-pointed bistoury, all that por- 
tion of the gland which is on a level with the concave borders of the arches. 
* Mackenzie, Diseases of the Throat and Nose, vol. i. p. 71. 990 
SURGICAL DISEASES OF THE MOUTH. 
It is never necessary to carry the incision nearer to the base of the tonsil 
than this. Both tonsils, when requiring it, should be removed at the same 
sitting. 
Generally the hypertrophy of these glands is not equally great: when 
this is the case, and the smaller of the two extends only a little beyond the 
pillars of the fauces, it will be sufficient to excise the major one alone. 
A little bleeding follows the operation, which soon ceases, or is readily con- 
trolled by gargling the throat with ice-water. The after-treatment is very 
simple, requiring confinement to the room for four or five days, and the use 
of a gargle of catechu and alum, or one of flaxseed tea containing a little 
tincture of myrrh. 
A very excellent mode of removing the tonsils is by an instrument styled 
a tonsillitome. There are several forms of the instrument, but the best, in 
my judgment, are those of Fahnestock, a physician of Lancaster City, and of 
Physick. Both consist of a ring composed of two plates, between which 
slides a knife with a stylet in front. 
In Fahnestock's instrument (Fig. 1G60) the knife is circular, and cuts by 
being retracted. 
Fig. 1660. 
Fahnestock's tonsillitome. 
In the tonsillitome of Physick the knife is fashioned like a chisel, and cuts 
by being pushed forward. (Fig. 1661.) Both act well; but I prefer that of 
Fahnestock. 
Fig. 1661. 
Physick's tonsillitome. 
It is essential to the satisfactory use of either that the knives have a very 
keen edge. 
In removing the tonsil by these guillotines, the ring is slipped over the 
Fig. 16G2. 
Kolbe's tonsillitome. 
hypertrophied growth and pressed well back towards its base; the stylet is 
then thrust forward, transfixing the body of the gland, when the knife is AFFECTIONS OF THE TONSILS. 
991 
quickly drawn back or pushed forward, according as the instrument of 
Fahnestock or of Physick is employed, when the projecting portion of the 
tonsil will be severed, and comes out, fastened to the stylet of the tonsil- 
litome. 
Another very ingenious instrument of the kind is the tonsillitome of Kolbe, 
which combines in one movement both the fixation and the excision of the 
gland. (Fig. 1662.) 
Though excision is not a painful procedure, yet, in consequence of not being 
able to obtain the co-operation of patients who are too young to understand 
what is to be done, an anaesthetic can be given with great advantage. 
Hemorrhage to any great degree after excision is quite uncommon. I can 
recall but a single instance in my own experience in which any anxiety was 
experienced from this cause. There is a condition of the gland which pre- 
disposes to bleeding. It is one due to the presence of chalky concretions, 
or of dense connective tissue, to which the vessels become adherent, and by 
which their walls are prevented from contracting. When the bleeding shows 
a disposition to continue, a strong solution of gallic acid, or a hot solution of 
alum, should be slowly swallowed. This may be assisted by the external 
application of ice, in a bladder or ice-bag, to the side of the neck below and 
behind the angle of the jaw. These measures failing, the bleeding surface 
should be touched with turpentine, alcohol, or Monsel's solution of iron. If 
the bleeding proceeds from two or three points, the quickest method of arrest- 
ing the oozing is with the point of actual cautery. A knitting-needle, in the 
absence of anything better, can be used for this purpose. Mr. McCarthy, in 
a case of excision of the tonsils followed by continued bleeding, at the London 
Hospital, tied the carotid artery with success. The operation of excision has 
sometimes been done in so reckless and bungling a manner that even the 
internal carotid artery has been wounded. Velpeau records four cases of 
this kind. Hemorrhage from an accident of this nature would require the 
ligation of the carotid. 
In patients who are weak or ansemic, the stump left after amputation of a 
tonsil will sometimes assume an indolent appearance, the granulations being 
pale and covered with a layer of gray lymph. A few applications of a crayon 
of nitrate of silver will soon change the appearance of the granulating surface, 
converting it into a healthy cicatrizing sore. 
Atrophy of the tonsils is so constant an attendant of old age that it might 
be regarded as a normal and not a morbid condition. Aftei' attacks of the 
severe form of angina, in which the inflammation has been attended with 
destruction of the connective tissue of the glands, atrophy is not uncommon. 
The change is of little importance and demands no interference. 
Ulceration of the tonsils arises from very diverse causes, as disturbance of 
the digestive organs, exanthemata, as scarlatina and diphtheria, and consti- 
tutional syphilis. When associated with derangement connected with the 
digestive organs, the ulcers are often multiple, never large or deep, and are 
covered with a film or patch of lymph. Those which depend on eruptive 
fevers are often large, deep, irregular sores, with adherent shreds or masses 
of dead connective tissue, and foul discharges, which charge the breath with 
a sickening odor. In both varieties of ulcers the other portions of the throat 
exhibit the signs of inflammation. In the former, however, the color, which 
is not very red, with the accompanying relaxation of the soft palate and 
arches, indicates chronicity; while in the latter, the tumid state of the parts, 
and their livid or dark leaden color, disclose a form of inflammation which is 
acute, but is at the same time destructive rather than reparative. 
Syphilitic ulceration is among the secondary accidents of the disease. The 
paternity of the sores is betrayed not only by the evidences of the taint in 
other parts of the body, but also by their being either multiple and with the 
characteristic sharp, well-defined edges, or solitary, penetrating deeply into 992 
SURGICAL DISEASES OF THE MOUTH. 
the structure of the tonsil, with ragged margins, steep, abrupt sides, and 
dark, offensive discharges covering the surface, with a tendency to enlarge 
and sometimes to become phagedamic. 
Treatment.-The therapeutical management of these different ulcers must 
be based on the causes which give them existence. If from indigestion, the 
treatment will include a very careful regulation of the diet, attention to the 
secretions, and the use of tonics, both vegetable and mineral, aided by pepsin 
at each meal. If attendant on certain exanthemata, they must be managed 
on principles applicable to such diseases; and if arising from syphilis, by the 
administration of remedies calculated to combat the blood-poison, the most 
valuable being the iodide of potassium, with the bichloride of mercury. 
Abscess of the tonsils has been noticed in connection with tonsillitis. In 
cases of this kind the suppuration is the result of acute inflammation; but 
there is another variety of abscess, the existence of which depends on chronic 
inflammation, and which is developed in a painless manner, and is quite cir- 
cumscribed, never attaining any great size. This abscess may appear in the 
course of convalescence from scarlet fever, diphtheria, or smallpox; it may 
be one of the manifestations of struma, or it may be due to the presence of 
a foreign body in the gland. When having a scrofulous origin, the glandular 
elements of the tonsil arc involved; when arising from septic or traumatic 
influences, the disease is located in the connective tissue. Multiple or dis- 
seminated abscesses of the tonsils are occasionally among the marked phe- 
nomena of pyaemia. 
The diagnosis of such an abscess is not difficult. Inspection will disclose 
a circumscribed swelling, soft and fluctuating to the touch, and having a gray 
or leaden-colored surface, indicating the true nature of the disease. 
Treatment.-In ordinary cases it is only necessary to puncture the swell- 
ing and give exit to its contents in order to effect a cure. But in those which 
depend on a strumous state of the system, and in which the pus presents a 
flaky or cheesy appearance, it may be necessary to touch the interior of the 
sac with the tincture of iodine or the solid nitrate of silver before securing 
its obliteration. 
Tumors of the Tonsils. 
Morbid growths of the tonsils are uncommon. Those which have been 
observed are the following: 
Cystoma.-Cysts have a twofold origin, namely, in the connective tissue, 
and also in the follicular portion of the gland. When located in the first, the 
tumor is deep-seated, and will escape observation for a long time. Those 
which have a follicular history are quite superficial, and are at once visible 
on inspecting the throat. Such a growth, when central, tends to produce 
atrophy of the gland, and in one case mentioned by Cohen was the cause of 
nervous aphonia. A tonsil cyst constitutes a painless, elastic tumor, without 
any evidences of inflammation. Its contents may be either caseous or ropy. 
The treatment will require the cyst to be laid open, and, after turning out 
its contents, the application to its interior of the compound solution of iodine 
or solid nitrate of silver. When the cyst is superficial, its entire excision is 
to be preferred. 
Fibroma of the tonsil has its seat in the connective tissue of the gland, and, 
like similar growths on mucous surfaces, it manifests a disposition to assume 
the pedunculated form. Tumors of this nature are dense, pale, nearly devoid 
of sensibility, and require to be clipped off below the mucous membrane. 
Lymphoma of the tonsil does not differ either histologically or in regard to 
treatment from strumous hypertrophy of the gland, which has already been 
considered. DISEASES OF THE SALIVARY GLANDS. 
993 
Carcinoma.-Medullary, epithelial, and scirrhous carcinomata occur in the 
tonsils, sometimes as primary affections, at other times as secondary to cancer 
elsewhere. The medullary form of the disease, however, is the most frequent. 
It is almost invariably limited to the gland of one side, is rapid in its prog- 
ress, affects males oftener than females, and is rarely seen under twenty 
years of age. The infiltration extends to the arches, palate, and surrounding 
parts; the lymph glands under the jaw and in the neck become infected, and 
as the growth increases it invades finally the mouth, larynx, and pharynx, 
interfering with articulation, respiration, and deglutition; the patient is at 
length destroyed either from repeated hemorrhages or from suffocation. The 
appearance and progress of the disease are so characteristic as scarcely to 
admit of its being confounded with other growths. The purple color of the 
tumor, the irregularity of its surface, and the rapidity of its growth reveal 
but too plainly its malignant character. While I have seen a few cases of 
both encepbaloid and epithelial carcinoma of the tonsil, only once have I 
witnessed an example of scirrhus, and this in a patient under the care of 
Dr. Detwiller, of Montgomery County, in this State. 
Treatment.-An operation can be considered proper only when the disease 
is strictly limited to the gland, and even then it is of very doubtful propriety. 
The only possible advantage which can be claimed for surgical interference 
is the probability of securing for the patient a less terrible death than when 
the disease is left to follow its natural course. To amount to anything it is 
necessary that the tonsil be removed in its entirety. This cannot be done 
without great risk to the internal carotid vessels, even when the enucleation 
is attempted with the fingers; and for this reason it will be better to adopt 
the method proposed by Blandin, of removing the gland through the neck 
from the outside. An operation of this nature will of course require not 
only accurate anatomical knowledge, but a degree of careful and deliberate 
dissection which not every one is qualified to undertake. This bold proce- 
dure was successfully practiced in one case by Dr. Cheever, of Boston. 
Sarcoma of the tonsil is less common than carcinoma. I have seen only 
two examples of the disease, both consecutive to general lympho-sarcoma, 
one in a female aged forty-four, and the other in a male about the same age. 
The tumors in the case of the female were in the groin, axilla, neck, and 
mammary gland. In both the disease proved fatal. No operation short of 
the complete extirpation of the gland, when the latter alone is affected, will, 
promise a shadow of relief; and this is so exceedingly uncertain that few 
surgeons will feel disposed to submit such a proposition to a patient for con- 
sideration. The operation, if undertaken, should be done through the neck. 
Poland* has reported two cases of extirpation by this route, one by Langen- 
beck and one by Hucter: that by the former is said to have been successful. 
DISEASES OF THE SALIVARY GLANDS. 
Sublingual Gland. 
Sublingual Cysts, Ranula.-The ducts of three different glands open into 
the mouth beneath the tongue, namely, those of the sublingual and submaxil- 
lary glands and of the glands of Rivini. The orifices of these excretory ducts 
are liable to become obstructed either from mechanical or inflammatory causes. 
The obstacle thus presented to the escape of the secretion causes the latter 
to collect, and, by dilating the duct or ducts, to form a tumor beneath the 
tongue, which is usually termed ranula. It has become common to speak 
of ranula as a dilatation of the submaxillary duct; but it would be better to 
discard the term altogether from surgical nomenclature and designate these 
tumors as retentive cysts, which may arise from the three independent 
* British and Foreign Medico-Chirurgical Review, April, 1872, p. 493. 
VOL. II.-63 994 
SURGICAL DISEASES OF THE MOUTH. 
sources already named. Whether the term ranula was given to this affec- 
tion on account of its color having some resemblance to that of the belly of a 
frog, oi' from the peculiar fullness that is sometimes seen to exist below the 
chin,-another characteristic of this reptile,-it is difficult to determine. 
These sublingual cysts arc met with chiefly in the young, and are some- 
times congenital. They vary in size from that of a cherry up to that of a 
walnut, have a spherical form, are semi-transparent, and present a gray or 
bluish color, marked on the surface with branches of the ranine veins: they 
arc unattended with pain. They may eventually, if left alone, attain to such 
dimensions as to displace the tongue, press their way into the neck, and in- 
terfere with the articulation. When one of these cysts attains considerable 
bulk, it will probably belong to the glands of Rivini, several being included 
in the disease, and occasioning multilocular ranula. If originating in the 
sublingual gland, it is not unreasonable to suppose that the obstructed duct 
or ducts give way, and that the tumor is due to an extravasation of saliva into 
the connective tissue, the latter becoming condensed, so as to form a limiting 
wall. 
Another variety of sublingual cyst, and one which may form very quickly, 
is thought by some to consist in an accumulation of fluid in a bursa described 
as being in connection with the genio-hyo-glossus muscle (supra-hyoid or 
bursa of Fleischmann), the fluid collecting in the sac in consequence of rup- 
ture of the submaxillary duct from overdistention. This bursa I have never 
been able to discover. 
The contents of sublingual cysts which are connected with the salivary 
glands are sometimes clear and watery, but oftener they are ropy like the 
white of an egg, and occasionally I have seen the fluid resemble a mixture of 
corn-meal and lymph. Dr. J. G. Richardson, of Philadelphia, describes a case 
in which the fluid contained rice-like bodies; and others have seen a substance 
similar to fat discharged from the sac. 
Treatment.-There are three methods of dealing with these sublingual 
sacs, namely, by partial excision, by the seton, and by injection. 
Partial excision is the simplest and most effectual method of cure. The 
surgeon, raising the prominent portion of the cyst with a pair of rat-toothed 
forceps, cuts away the front half of the tumor with a pair of scissors curved 
on the flat, and, after the contents have escaped, swabs the cavity of the 
sac with the tincture of iodine, or rubs its 
interior with a stick of nitrate of silver. 
(Fig. 1663.') 
Seton.-This is applied by introducing a 
needle, armed with a silk thread, through 
the cyst, and, after tying the ends of the 
seton together, allowing it to remain until 
the necessary inflammation has been ex- 
cited to secure the obliteration of the cyst, 
which may require six or seven days. 
Injection. - The treatment by injection 
consists in puncturing the sac, and, after 
discharging its contents, inserting the nozzle 
of a syringe and depositing eighteen or 
twenty drops of the tincture of iodine. 
There are cases of cyst-like swellings 
under the tongue which occur suddenly, 
the subglossitis of Ealthouse: these are ex- 
amples, I believe, of local anasarca, or sub- 
lingual dropsy, and demand no surgical 
operation, disappearing with the inflammation which produced them. 
In two instances I have excised from beneath the jaw large cysts which 
made very little show in the mouth, and which I am disposed to believe, from 
their history and contents, were originally due to rupture of the submaxil- 
Fig. 1663. 
Excision of ranula. DISEASES OF THE SUBMAXILLARY GLAND. 
995 
lary duct; and in one case reported by Dr. Garretson, of a similar nature, 
the probability of such an origin is strengthened by the fact that he dis- 
covered, during the removal of the cyst, the fistulous communication between 
the tumor and the sublingual gland. 
Cysts containing some solid material, similar to sebaceous tumors of the 
scalp, are occasionally met with beneath the tongue, and require that the 
wall of the cyst shall be dissected out as far as possible, applying to that 
which remains either nitrate of silver or tincture of iodine. Bryant thijiks 
these encysted tumors are congenital; but I met with one beneath the tongue 
of a clergyman which had made its appearance only three years before he 
consulted me. 
Carcinoma of the sublingual gland is rarely met with, except when the 
disease has extended to the gland from adjacent parts. Gross mentions two 
cases in which the tumor was primary. 
Diseases of the Submaxillary Gland. 
The submaxillary gland is occasionally the seat of cysts, of carcinoma, 
sarcoma, enchondroma, and calculi. 
Cystic Growths of the submaxillary may arise from a dilatation of some 
of the tributaries of the duct of Wharton, forming a soft fluctuating tumor 
beneath the jaw. When the main duct becomes dilated into a cyst, the 
swelling will appear in the floor of the mouth, or under the tongue, rather 
than in the neck, in which direction greater resistance would be encountered. 
Many of these so-called submaxillary cysts, however, are cystic degenerations 
of the lymph gland, which rests on the former. I have frequently removed 
such growths and found the salivary gland intact beneath. 
A cyst situated in or about the submaxillary gland may be determined by 
the boundaries of the tumor. No region is so perfectly defined by structural 
boundaries as the submaxillary. Hence, when the tumor does not extend 
posteriorly behind the angle of the jaw, or inferiorly below the great horn of 
the hyoid bone, and when anteriorly it is outlined by the crescentic sweep 
of the digastric muscle, its limitation to the submaxillary region may be 
confidently affirmed. 
Excision is the proper remedy for such cysts. 
Enchondroma is sometimes met with in the submaxillary gland, forming 
a hard, knotty, or lobulated tumor, which grows in a slow and painless man- 
ner and is firmly imbedded in position. These growths are made up of 
masses of different kinds of cartilage, with intermediate strata of connective 
tissue, and sometimes undergo partial calcification or ossification. They will 
require to be removed by excision. 
Adeno-Sarcoma.-Neoplasms of this character are at first very deceptive. 
They begin much in the same manner as an adenoma of the gland. The 
growth is steady, uniform in all directions, and painless, with no tendency to 
discoloration, ulceration, or attachment to the skin. Tumors of this kind 
require to be removed by the knife, but are likely to return. In one which 
I excised, the growth did not reappear until eight months after the opera- 
tion. 1 
Carcinoma.-The submaxillary gland becomes the seat of cancer, both 
primary and secondary. Primary cancer of the gland is generally of a 
scirrhous nature, and occurs in adults. The leading characteristics of a 
tumor of this nature are extreme hardness, irregularity of surface, immo- 
bility, and darting pains. It grows rapidly, acquiring considerable bulk ; the 
skin becomes discolored, adherent, and ulcerates, and if the tumor develops 996 
SURGICAL DISEASES OF THE MOUTH. 
towards the floor of the mouth it will displace the tongue and embarrass 
articulation, mastication, and deglutition. The lymphatic glands of the neck 
contiguous to the submaxillary become infected and enlarged. Secondary 
carcinoma of the gland is induced by an extension of the disease from parts 
which are adjacent, as in cancer of the tongue or of the jaw. 
Diagnosis.-The affections with which it is possible to confound carcinoma 
of the submaxillary gland are cysts, lymphoma, sarco-lymphoma, and en- 
chondroma. 
The smooth, soft, elastic, and fluctuating properties of the cystic tumor 
are in such striking contrast with the irregular, hard, and unyielding surface 
of scirrhus as scarcely to admit of error. Lymphatic tumors are generally 
met with in young persons, are movable, firm, but not hard, show no ten- 
dency to become adherent to the skin, not unfrequently break down and 
suppurate, and do not contaminate the general system. 
The points of distinction between scirrhus and sarcoma are the elastic feel, 
uniform smoothness of surface, absence of pain, discoloration of the overlying 
skin, and absence of tendency to ulceration which characterize the latter, 
cancer presenting in each instance the reverse condition. 
Enchondromata greatly exceed in hardness and- irregularity of surface 
scirrhous tumors, nor do they tend to ulceration, discoloration of skin, or the 
production of a cachexia like the latter. They are also comparatively free 
from pain, and quite slow in their growth. 
Calculi.-Calculous concretions are frequently discovered in the submax- 
illary. They are usually somewhat cylindrical or elongated, and are com- 
posed of phosphate and carbonate of lime, held together by some organic 
matters derived from the salivary secretion. They sometimes attain con- 
siderable size, and, by filling up and distending the duct, give rise to cystic 
accumulations. The presence of a body of this nature can be discovered, 
when it is not visible beneath the mucous membrane of the mouth, by press- 
ing the floor of the latter on the affected side between the two fingers, one on 
the inside of the oral cavity and the other beneath the jaw. In all cases of 
sublingual cysts an examination for salivary calculus should be instituted. 
These concretions are sometimes found at the commencement of the sub- 
maxillary duct before it leaves the gland, or even in the radicles of the duct, 
in the midst of the gland-tissue, causing a diffuse suppuration of the sub- 
maxillary. 
Treatment.-The calculus is to be removed by making an incision through 
the wall of the attenuated duct, and scooping the concretion out, either with 
the finger-nail or with the concave end of a director, or by dragging it away 
with the forceps. 
Removal of the submaxillary gland.-The patient being placed on a table, 
with the shoulders raised, and the head well thrown back, and turned to the 
side opposite to the one affected, a crescentic incision in the cavity below is 
made over the affected gland through the integument, extending from the 
angle of the jaw to the base of the bone, about one inch short of the 
symphysis. 
The platysma myoides and deep fascia are next to be raised on a director 
and divided, when the gland, or any tumor occupying the same region, 
will be exposed. After incising or breaking up a layer of connective tissue 
which fastens the gland to the tendon of the digastric and the great horn 
of the hyoid bone, the submaxillary can easily be separated with the finger 
from its connections with the hyo-glossus and mylo-hyoid muscles beneath, 
and turned over upon the face. Before entirely dislodging it, the facial 
artery, which enters the gland at its inner and lower border, will require 
ligation, after which, dragging the mass from its bed with a vulsellum, and 
putting its deep attachments on the stretch, they can be severed, and the 
submaxillary removed without injury to the hypoglossal nerve, which lies 
between the gland and the hyo-glossus muscle. DISEASES OF THE PAROTID GLAND. 
997 
Diseases of the Parotid Gland. 
The affections of the parotid gland which often call for surgical inter- 
ference are parotitis, abscess, salivary fistula, salivary calculus, and morbid 
growths. 
Parotitis, or Mumps, is an inflammation of the parenchyma of the parotid 
gland, and of an infectious nature. It is a disease almost exclusively confihed 
to the young, though occasionally seen in persons in middle life. It is more 
common in the winter and spring months, and one attack generally secures 
an exemption from a second. 
Symptoms.-The attack of parotitis is ushered in by a sense of soreness 
and stiffness of the jaws, and a swelling in front of the ears, extending down 
to the angle of the jaw, very sensitive to the touch or to any movements of 
the maxilla. As the disease advances, deglutition becomes painful, and there 
is frequently some degree of febrile excitement. The acme of the inflamma- 
tion is reached on the fourth day, after which the disease gradually declines, 
and in six or seven more days entirely disappears. 
The inflammation in parotitis has a singular and wholly inexplicable ten- 
dency to recede suddenly from the affected gland and to attack the testis or 
the mammary gland. This may occur not only during the active stage, but 
even when the disease is on the decline. 
Aggravated cases of parotitis, particularly if the system has been weakened 
by previous disease, are liable to terminate in abscess; and the same result 
occasionally occurs as a sequel of low forms of certain exanthemata, as 
scarlatina and smallpox, typhoid fever, or erysipelas. Even gangrene may 
follow after such antecedents. 
Treatment.-Parotitis, having a specific course to run, rarely demands any 
other treatment than rest, confinement to the room or bed, a gentle aperient, 
a liquid diet, and warm lotions of laudanum and water, or a hot solution of 
muriate of ammonia and laudanum. 
The induration due to the inflammatory infiltration of the gland, which 
often remains after the acute symptoms have passed away, will generally 
disappear without special treatment; but should it prove tardy in this respect 
the process may be hastened by stimulating frictions with soap liniment con- 
taining a little iodide of potassium and oil of amber, or by painting over 
the gland with the compound solution of iodine. 
When the disease is translated to the testicle, an attempt should be made 
to re-establish the inflammation in the gland by applying a blister over its 
surface. If this proves unsuccessful, the case must be treated as one of or- 
chitis, by leeches along the course of the cord, followed by vesication, pro- 
duced by drawing a stick of nitrate of silver longitudinally over the scrotum 
at three or four places, and by the internal administration of the iodide of 
potassium and the bichloride of mercury. 
Abscess of the parotid is indicated by a swelling defined by the boundaries 
of the gland, a dusky discoloration, and oedema of the overlying integument. 
The suppuration is attended with great pain, rigidity of the jaws, rigors, and 
other signs of much constitutional disturbance. If not early recognized, and 
if allowed to go unrelieved, the swelling will extend over the entire side of the 
face, and even to the eyelids. These abscesses are diffused, not circumscribed ; 
the pus finds its way through the cartilage into the ear, or travels into the 
neck, causing extensive and in some instances fatal disorganization of the 
tissue, and pyaemia. 
Treatment.-As soon as the existence of pus is detected, an incision must 
be made through the skin and the superficial and deep fascia, dividing the last 
two layers on the director, in order that the gland-tissue proper shall not 
be opened,-an accident which is liable to be followed by a salivary fistula, 
which is often difficult to close. The incision, when feasible, should be 998 
SURGICAL DISEASES OF THE MOUTH. 
near the lower part of the gland, thus favoring by its dependent position 
the drainage of the abscess. After the parotid has been exposed, should 
the pus not flow, the interlobular connective tissue will require to be broken 
away by the end of a director at the softest part of the gland until the 
collection is reached, when the opening must be kept pervious by the in- 
troduction of a drainage-tube until the suppuration ceases. It will be 
necessary, after the opening has been made, to apply over the parts hot 
flaxseed-meal poultices for a few days, until the tissues have become un- 
loaded and contracted. When from delay the pus has found its way into the 
neck, it is equally important, in addition to opening a way into the gland, to 
reach the collection in the neck, first by the formal division of the skin, super- 
ficial fascia, platysma myoides muscle, and deep fascia, and afterwards by 
conducting the dissection with the end of a probe. The constitutional dis- 
turbance attending a parotid abscess is of a character to demand tonics, 
stimulants, and the best food. 
Salivary Calculus.-Concretions of this kind are sometimes formed in the 
duct of Steno, and are of the same chemical composition as those met with 
in the duct of Wharton or in the sublingual ducts. They are cylindrical in 
form, and lie parallel with the long diameter of the duct. 
In one case the calculus measured an inch 
and a half in length (Fig. 1664), and formed a 
very prominent ridge on the outside of the face. 
A concretion of this nature will obstruct the 
passage of the saliva into the mouth, causing the 
gland to swell from the retained secretion, and 
may be detected by pressing the cheek between 
the fingers, placed one on the inside and the 
other on the outside, in the line of the duct. If allowed to remain, ulcera- 
tion of the cheek may follow, and as a consequence a salivary fistula. 
Treatment.-The calculus should be removed from the inside of the 
mouth by opening the duct and extracting the concretion with the finger, 
scoop, or forceps. 
Fig. 1664. 
of steno. 
Salivary Fistula of the parotid duct has been discussed in connection with 
wounds of the face. (See vol. i. page 313.) 
Nervous Enlargement of the parotid is a rare affection. I had under my 
care during the winter of 1879 a very marked case of this kind in a lady of 
a highly-emotional temperament. When the attacks came on, they were 
generally preceded by some mental excitement. Both glands in a few min- 
utes would enlarge, and a sense of fullness would be experienced in the neck, 
accompanied with a constant desire to swallow. 
Emotional causes act in producing increased secretion of saliva and give 
rise to the swelling of the glands in a different manner from those reflex 
impressions which are transmitted through the lingual and chorda tympani 
nerves under the excitation of food. Their effect must be explained by a 
consideration of the communications between the sympathetic and excito- 
secretory branches of the gland. 
The treatment in emotional enlargement of the parotid must bo chiefly 
moral, with the assistance of antispasmodics, the best of the class being 
either bromide of potassium or assafeetida. 
Tumors. 
The morbid growths which find a habitat in the parotid gland are cystoma, 
fibroma, enchondroma, sarcoma, adenoma, carcinoma, myxoma, and lipoma. 
The gland is also remarkable for the compound character of its neoplasms, 
many of these possessing the histological elements of both myxoma and TUMORS OVER THE PAROTID. 
999 
fibroma, of myxoma and enchondroma, of myxoma and carcinoma, of cys- 
toma and sarcoma, and of lipoma and sarcoma. 
It is exceedingly difficult, in a soil so fruitful in producing these multi- 
tudinous and complex growths, to attempt a nice clinical differentiation or 
classification. 
As a practical clue in threading this labyrinth, some general rules may be 
formulated. 
If we assume that the time allotted to morbid growths of the parotid rarely 
extends beyond the fiftieth year of life, and if we divide this into three 
periods, namely, one between eighteen and twenty, one between twenty and 
thirty-five, and one between thirty-five and fifty, it will be found that in most 
instances those growths which occur within the limits of the first period are 
myxoma, enchondroma, carcinoma, particularly of the soft variety, and 
cystoma; those which appear in the course of the second period are sarcoma 
and fibroma; and those which arise within the third period are carcinoma, 
of the scirrhous and epithelial varieties, and lipoma-sarcoma. 
A very important differential sign between those tumors of the parotid 
which are malignant and those which are benign is the tendency in the 
former to infect the lymph glands. 
Again, some approximate idea of the nature of parotid tumors can be 
obtained by considerations of growth, character of surface, density, mobility, 
and pain. Those which grow most rapidly are the encephaloid variety of 
carcinoma and sarcoma. The skin over the former growths soon becomes 
purple and adherent to the surface, ulceration following at one or more 
points, and through the opening protrude masses of fungoid granulations, 
which furnish an unhealthy ichorous discharge having a very offensive smell. 
Encephaloid growths have a soft and elastic feel, and soon poison the neigh- 
boring glands. 
Sarcomata, while they frequently increase quite rapidly in size, do not 
grow with the speed of encephaloid disease. They have a doughy rather 
than an elastic feel, and the skin, notwithstanding that it becomes stretched 
and attenuated by the growth of the tumors, exhibits little tendency either to 
discoloration or to adhesion to the surface of the growths. Those tumors 
which progress more slowly are enchondroma, fibroma, cystoma, and scir- 
rhus. Except the last, these growths are all movable in their early history, 
becoming more fixed, and even immovable, as they increase in size. 
Enchondroma, in consequence of its extreme hardness and its knobby or 
irregular surface, can usually be differentiated from the others. Fibrous 
tumors, though very firm in their consistence, are less so than the cartila- 
ginous, besides possessing a more uniform exterior. 
The elasticity of cysts, partaking somewhat of the character of fluctuation, 
will furnish an important diagnostic sign; while the small, dense, inelastic, 
fixed, tardily-growing scirrhus, with its accompanying shooting pains, can 
scarcely be mistaken for any other disease. 
The Accessory Parotid.-This is the name given to a number of lobules 
which lie beneath the zygoma and are in great measure detached from the 
main mass of the gland. This part of the parotid, though less liable than 
the main gland to become the seat of disease, is by no means exempt. 
All neoplasms in this situation, which in their histological elements are 
composed either exclusively or in part of gland-tissue, are by many writers 
believed to commence in this accessory parotid. 
Tumors over the Parotid. 
Lymphoma,-In the loose connective tissue which covers the parotid fascia 
lie a number of lymphatic glands, which are frequently the subject of morbid 
changes, especially of a strumous or tubercular character. The same bodies 
may undergo cystic, enchondromatous, or sarcomatous degeneration, giving 1000 
SURGICAL DISEASES OF THE MOUTH. 
rise to tumors of their different classes, each of which presents the charac- 
teristics of the neoplasm to which it belongs. 
Fibrous Tumors also arise in the connective tissue covering the parotid 
gland, and frequently acquire considerable size. Whatever may be the char- 
acter of these tumors, they tend after a time to cause the absorption of the 
parotid fascia, and finally to imbed themselves in the substance of the paro- 
tid, or even to cause by pressure its entire destruction, the new formation 
occupying the original seat of the gland. 
To distinguish between parotid and supra-parotid tumors is by no means 
difficult. The former, even when most benign, never admit of much mo- 
bility, while the reverse is true in regard to the latter. Even when a 
superficial growth has gradually destroyed the parotid and taken its place, 
and has become more fixed, inquiry will bring out the fact that it was freely 
movable at an earlier period. 
Another important topographical difference exists between parotid and 
supra-parotid tumors. Those which are seated primarily in the parotid 
gland are, during a considerable period of their history, confined strictly 
within certain boundaries, namely-above, the zygoma; below, a line extend- 
ing from the angle of the jaw towards the mastoid process of the temporal 
bone; posteriorly, the temporal bone and the cartilage of the ear; anteriorly, 
the posterior border of the masseter muscle and the angle of the jaw ; while 
those which are seated over the parotid region, when they acquire con- 
siderable bulk, have no such sharp definition, 
but extend in the direction of least resistance, 
or rise from a narrow base. (Fig. 1665.) 
Treatment.-Extirpation of the parotid gland 
is perhaps the most difficult operation in sur- 
gery. Professor Gibson, even until the time of his 
death, stoutly maintained that the operation was 
impossible. Viewing the subject from the stand- 
point of normal anatomy, such an opinion is 
quite tenable; but when the changes produced 
by disease are considered, a different conclusion 
will be reached, as under the influence of the 
latter the components of the gland (especially 
in fibroma, enchondroma, and scirrhus) are 
firmly bound together, and admit of the gland or 
tumor being dragged out of the irregularities of 
the region, in its totality, without breaking up 
into fragments. In encepbaloid and sarcoma, if 
once the capsule of the gland has given way, 
and the disease passed beyond its limits, the task of extirpation is as difficult 
as it is hopeless. 
There are not less than 108 cases recorded in which the evidence of the 
entire gland having been removed scarcely admits of a doubt. 
Surgical anatomy.-The parotid space is a deep fissure, bounded in front 
by the posterior margin of the ramus of the inferior maxillary bone, behind 
by the auditory canal and the mastoid process of the temporal bone, above 
by the zygomatic arch, and below by a line extended horizontally back from 
the angle of the jaw to the sterno-cleido-mastoid muscle. The region is 
broadest below, gradually contracting into a fissure above. 
The stylo-maxillary fascia completely isolates the parotid from the sub- 
maxillary region. The deep surface below is formed by the styloid process 
and the bouquet of Biolan, or that radiation of muscles and ligaments which 
fakes place from the process. The parotid, which fills up the space thus 
defined, is tunneled by the external carotid, which as it emerges from the 
gland above divides into the temporal and internal maxillary arteries. It 
is traversed by the cervical, facial, and temporal branches of the facial or 
Fig. 1665. 
Fibrous tumor over parotid gland. TUMORS OVER THE PAROTID. 
1001 
portio dura nerve, also in an upward direction by the temporal branch of 
the inferior maxillary nerve, and below by the tcmporo-parotid vein, the 
chief tributary of the external jugular. At the posterior border of the gland, 
between the latter and the mastoid process of the temporal bone, pass out 
the posterior auricular artery, the auricular branches of the superficial cervi- 
cal plexus, and the facial nerve. Immediately beneath the floor of the parotid 
space lie the internal carotid and the internal jugular vein, also the spinal 
accessory, glosso-pbaryngeal, and pneumogastric nerves, and a small portion 
of the hypoglossal. The lymph glands which rest on the parotid fascia form 
a continuous chain with those of the neck. 
It will be apparent from the general outline of the components of the 
parotid and of the adjacent regions that the removal of the gland is an 
operation which involves accurate anatomical ideas guiding a cool, deliberate 
dissection, and is never to be rashly undertaken. The rule laid down by Sir 
William Fergusson for the removal of parotid tumors is based on their mo- 
bility. If immovable, extirpation should not be attempted. I would restrict 
extirpation to benign growths. An operation for the removal of those which 
are malignant is powerless to prevent a recurrence of the malady, and mate- 
rially shortens life. 
Operation.-I have twice removed the gland entire, and in describing its 
excision I shall confine myself to the plan adopted in both operations. 
The patient should be placed upon a table, with the shoulders elevated, 
and the head turned to the opposite side from the one affected. An incision 
is next carried from the zygoma, over the middle of the tumor, down to a 
point a short distance below a line drawn from the angle of the jaw, hori- 
zontally across the neck, to the sterno-mastoid muscle. In very large tumors 
it may be necessary to add to this another incision at right angles with the 
first, or to make two elliptical cuts. The integument is next dissected from 
the growth, anteriorly and posteriorly, turning the flaps over the face and 
the ear, making as ample an exposure of the growth as possible. Any ves- 
sels which bleed freely during this stage of the operation must be tied, or 
secured with artery forceps. Next let the dissection be carefully made at 
the lower or cervical extremity of the tumor, until that portion of the growth 
can be detached, when it should be drawn outward and upward by a vul- 
sellum. In doing this, the external carotid artery will be raised from its 
bed, and, after being isolated from any adherent shreds of connective tissue, 
must bo tied at two places and divided between. By drawing the tumor -well 
forward, and keeping the edge of the knife, or the handle of the same, close 
against its surface, the auricular nerve and the branches of the superficial 
cervical plexus can be avoided. The finger may at this stage do the work 
of the knife, and should always be preferred to the latter as the safer 
instrument, so long as the deep attachments of the tumor yield to its press- 
ure, aided by simultaneous traction. In dislodging the gland from its bed, 
the portio dura nerve, if the tumor is one primarily implicating the gland, 
must necessarily be divided. Directions which are sometimes given with 
reference to avoiding this nerve in the extirpation of the parotid are prac- 
tically useless, unless the substance of the growth is very soft or friable, when 
the cervical branch, with the main cord of the nerve, may be separated by 
the careful use of a director, and the facial paralysis thereby lessened in 
extent. 
Of greater importance, however, is the safety of the internal carotid artery 
and jugular vein, together with the nerves which lie in their company. 
These, being immediately beneath the parotid region, are necessarily in dan- 
gerous propinquity, and might easily be dragged from their own into the 
region under consideration, and thus be exposed to injury. Indeed, the jugu- 
lar vein is frequently obliterated by the pressure of the tumor. Every strip 
of tissue, therefore, which continues to fasten the parotid tumor dowTn in 
this locality must receive a most careful inspection with the eye before being 
divided. 1002 
SURGICAL DISEASES OF THE MOUTH. 
The upper portion of the gland is the last extirpated, and the operation 
here necessarily involves the division of the internal maxillary and temporal 
arteries. As these vessels have an extensive range of anastomoses, it is well 
to place a ligature around the trunk of each, and thus diminish the risks of 
subsequent hemorrhage. After the extirpation is completed, the flaps are 
to be replaced, united by sutures, and supported with a compress of lint 
moistened with carbolated oil, and covered with a pad of oakum, both being 
secured by vertico-maxillary turns of a roller. 
In removing tumors which are situated over the parotid, the most impor- 
tant object to keep in view is the separation of the growth from the gland 
beneath without opening any of the lobules, an accident which is likely to 
be followed by a salivary fistula. For this reason, enucleation should take 
precedence of dissection with the edge of the knife whenever possible. 
The extirpation of the parotid gland was first performed in America by 
Warren, of Boston, in 1798. This operation pioneered the way for those of 
McClellan, of Greencastle, Franklin County, Pennsylvania, in 1805, of White, 
of Hudson, New York, in 1808, and of Sweat, of Maine, the last-named sur- 
geon having repeated the extirpation three times between the years 1811 
and 1841. It was not until 1826 that Dr. George McClellan, of Philadelphia, 
whose name is more prominently associated with this operation than that of 
any other surgeon, made his first excision of the parotid. The patient was 
a medical student, on whom a previous but unsuccessful attempt had been 
made in Dublin to extirpate the gland. The case, though attended with 
considerable difficulty and hazard to life, was brought to a successful termi- 
nation, the individual making a permanent recovery. 
The operation of tying the carotid has been adopted in a few cases of 
parotid tumors, where extirpation was not deemed advisable, with a view to 
induce atrophy of the growth by cutting off the supply of blood. The 
method is said to have been successful in two or three instances in the hands 
of Ilossack, of New York; but the facility with which the blood, through the 
collateral vessels, again reaches the gland, renders the practice scarcely 
worthy of imitation, if undertaken on the principle of starvation. 
Wounds of the duct of Steno have been discussed under the head of 
Injuries of the Face, vol. i. p. 313. 
Affections of the Pharynx and (Esophagus. 
General Considerations.-In order to examine the pharynx, the only 
instrument ordinarily required is a tongue-depressor (Fig. 1666), in the 
absence of which a spatula or the handle 
of a large spoon will answer every pur- 
pose. The patient should be placed before 
a good light and directed to open the 
mouth, when the dorsum of the tongue is 
to be depressed with the instrument. 
In many persons the reflex sensibility 
of the fauces and pharynx is so great that 
the simple contact of the instrument with 
Fig. 1666. 
Fig. 1667. 
Ton gue-depressor. 
Pharyngoscopic mirror. 
the tongue is sufficient to excite violent muscular contraction in these mus- 
cles and defeat the object in view. With such patients a very good view of 
the parts can be obtained by requesting them, after opening the mouth, AFFECTIONS OF THE PHARYNX AND (ESOPHAGUS. 
1003 
either with or without the protrusion of the tongue, to take a strong in- 
spiration. A pharyngoscopic mirror (Fig. 1667) will sometimes be found 
useful in obtaining an image of recesses of the pharynx which otherwise 
could not be fairly explored by the unassisted eye. 
As mucus is often found adhering to portions of its surface, a delicate 
metallic scraper or curette (Fig. 1668) will prove useful in removing such 
accumulations. 
Fig. 1668. 
Scraper. 
Congenital defects.-Malformations of this nature possess little interest for 
the surgeon, as they are generally incurable or associated with other imper- 
fections which are fatal to the life of the child. Thus, the pharynx may 
terminate in a cul-de-sac behind the larynx, the oesophagus being absent, or 
it may open on the surface of the neck. 
Neuroses of the Pharynx. 
Disorders of sensation or of motion are frequently observed in this part of 
the alimentary tube. 
Disorders of Sensation. 
Anaesthesia.-The most remarkable instances of diminished pharyngeal 
sensation are witnessed among the insane; and the diminution of sensation 
accounts for their ability to introduce into the alimentary passages divers 
materials of great size and irregularity of surface. Certain diseases, as diph- 
theria and paralysis, have the effect of lowering the sensibility of these parts. 
Anaesthetics induce a like condition, though in a different way. 
Hyperaesthesia is often due to a natural exalted state of reflex irritability, 
and can frequently be greatly lessened by familiarizing the parts with the 
contact of instruments. Among the common causes of hyperaesthesia from 
morbid conditions are elongation of the uvula, tonsillitis, catarrhal pharyn- 
gitis, laryngeal phthisis, disease of the cervical vertebrae, and the lodgment 
of foreign substances in some of the loose folds about the arches or the root 
of the tongue. Pharyngeal irritability is common among smokers, in conse- 
quence of the follicular disorder induced by tobacco. 
The normal irritability of the pharynx has a certain value, of which ad- 
vantage may sometimes be taken. Thus, in croup, with large accumulations 
of laryngeal and tracheal mucus, and when the depressing effects of emetics 
are to be avoided, the titillation of the fauces and pharynx with a feather 
or the finger will induce those muscular contractions which are sufficient to 
effect expulsion. 
In the same manner a stomach overloaded with crude and indigestible in- 
gesta, threatening cerebral trouble or colic, can be relieved of its contents, 
or quick emesis can be promoted when poisonous substances have been 
accidentally swallowed. 
The hyperaesthesia sometimes becomes so great that nothing whatever can 
be swallowed without provoking spasm. 
As hyperaesthesia, when it assumes the importance of a disease, is often 
secondary to morbid conditions in the adjacent parts, it will be necessary to 
seek for these, and, as far as possible, remove them. Whatever may be their 
character, whether resulting from inflammatory changes, from the presence 1004 
SURGICAL DISEASES OF THE MOUTH. 
of foreign bodies, or from hurtful habits, the irritability will be lessened by 
the internal use of the bromide of potassium, and by painting the pharynx 
once daily with a solution of nitrate of silver or tincture of aconite. When 
spasm exists, precluding alimentation by the mouth, the patient can be 
nourished by nutritious enemata. 
Perverted sensations are almost peculiar to women, and frequently owe their 
existence to a hysteroidal state, though the latter may have a real physical 
basis, as is often seen in uterine disorder or while a woman is passing through 
the perturbation of the menopause. Under the head of perverted pharyn- 
geal sensibility come cases of foreign bodies in the throat which have no ex- 
istence except in the imagination of the patient. I have known the idea of 
a fish- or chicken-bone to harass a nervous individual for months; and in one 
instance the medical attendant was so far deceived by the representations of 
the patient as to have denuded in mistake the great horn of the hyoid bone 
in ineffectual attempts to drag away what was supposed to be a foreign body 
fastened in the wall of the pharynx. An ever-present fruitless hawking or 
coughing is also among the nervous disturbances of this part of the gullet. 
It is never proper, however, to dismiss these cases without a careful ex- 
amination, so as to exclude the possibility of error, and when satisfied that 
these sensations have no foundation in fact, then attention must be given to 
the general health, and to the removal of any detectable cause to which their 
existence might be referred, together with the use of the bromides and other 
antispasmodics. I have known the physician intentionally to fall in with the 
delusion, and by a little professional sleight of hand endeavor to lead the 
patient to believe that the material cause of the local trouble had been 
removed, but never with success: indeed, I have no faith in either the thera- 
peutics or the morality of professional deception. Nor is the method some- 
times resorted to, of ridiculing and badgering the patient with regard to an 
infirmity, to be commended. More will be gained by honestly informing the 
subject of the sensations that they are real, but that they proceed from causes 
different from those supposed. 
Disorders of Motion. 
The muscles of the pharynx are subject to different disorders affecting 
their mobility, some of which are hysterical, while others are central. 
Nervous Dysphagia is generally met with in females and those whose health 
has been damaged by exhausting disease. The chief characteristic of the 
muscular disorder is an inability to swallow food, especially solids, particu- 
larly when in the presence of others. It does not necessarily indicate any 
organic disease, but it is occasionally among the first symptoms of stricture 
of the oesophagus, even before the structural changes arc sufficient to offer 
any sensible mechanical impediment to the passage of food. When not due 
to organic disease, the remedies for its relief are those which aid in restoring 
the general strength and vigor of the body, as tonics, antispasmodics, con- 
centrated nourishment, and a life in the open air. 
Chorea of the pharyngeal muscles, due to a loss in the inhibitive or co- 
ordinating government of this portion of the apparatus of deglutition, will 
sometimes occur. There is not in these cases the timidity or irresoluteness 
of will in swallowing that belongs to pure nervous dysphagia. On the con- 
trary, persons who labor under this affection, and who are usually young 
females, make repeated and persistent efforts at deglutition ; they will delib- 
erate, and choose a seemingly opportune moment to endeavor to transmit the 
bolus of food to the oesophagus. The disability will yield to iron, arsenic, 
and the shower-bath. 
Paralysis of the muscles of the fauces and pharynx is a common attendant INFLAMMATORY AFFECTIONS OF THE PHARYNX. 
1005 
on diphtheria, and one which will frequently remain long after all other mani- 
festations of the disease have disappeared. In attempting to swallow fluids, 
they are found to pass into the nose, partly because the velum, participating 
in the paresis, is unable to shut off the post-nasal from the post-faucial space 
of the pharynx. The gradual loss of power in the pharyngeal muscles of 
deglutition is also a prominent symptom in bulbar paralysis; it commences 
in the tongue, advances a little later to the lips, and at length reaches the 
palate and pharynx. 
This disease is rarely encountered under thirty years of age. The involve- 
ment of the oral as well as of the faucial and pharyngeal muscles affects not 
only deglutition, but also articulation, phonation, and salivation, the saliva 
constantly dribbling from the mouth. Pharyngeal paresis may arise from 
syphilitic disease, and is then calculated to create the greatest anxiety, de- 
pending as it does on central changes, which may suddenly terminate life in 
a convulsion. 
Unilateral loss of pharyngeal power may also attend paralysis of the face. 
Diphtheritic paralysis is removed only by time, aided by the use of iron 
tonics, food, and good air. 
Bulbar paralysis, originating as it does in sclerosis and other degenerations 
in the gray matter of the medulla oblongata and upper end of the cord, is 
incurable. 
Syphilitic paralysis demands the prompt administration of large doses of 
the iodide of potassium with mercurial inunction. 
The loss of power which attends faucial paralysis will be recovered in case 
the latter improves. The remedies which aid in bringing about this result 
are the iodide of potassium, with or without alterative doses of mercury, in 
the early stage of the affection, and latex* strychnia, with the cautious use 
of electricity. 
Neuralgia of the pharynx is described by some writers. The symptoms 
are pain, generally unilateral, sometimes dull, at other times acute, accom- 
panied by a sense of constriction, and with occasional muscular spasm. The 
subjects of the affection are usually young girls, anaemic and out of health; 
but women of mature years laboring under uterine disorders are also affected. 
While I have frequently seen patients who complained of anomalous and 
painful sensations in the throat, I have never thought that the attacks, 
which were not severe and were without any periodical or paroxysmal 
feature, were entitled to the name of neuralgia. These cases were, more- 
over, relieved by antispasmodics, particularly the bromide of potassium, which 
confirmed me in the opinion of their being nervous rather than neuralgic. 
The treatment in a case of pharyngeal neuralgia, should such occur, would 
be the same as when the disease fixes on other regions of the body, namely, 
quinine, arsenic, iron, and piperine. 
Inflammatory Affections of the Pharynx. 
Inflammation of the pharynx occurs from both common and specific causes. 
Pharyngitis from common causes, as cold and sudden alterations in temper- 
ature, is popularly known as sore throat, and is usually an inflammation 
which includes the fauces as well as the pharynx. 
A little dryness and stiffness of the throat, followed by a feeling of sore- 
ness, which renders deglutition uncomfortable, and the abundant formation 
of tenacious mucus, preceded in some cases by a sense of chilliness, are the 
symptomatic phenomena which characterize the disease. The inflammation 
subsides ordinarily in a few days, requiring nothing more than confinement 
to the house. A gentle aperient, followed by a few doses of neutral mixture, 
is generally all that is required in the way of medicine. If the throat con- 
tinues to remain sore, a gargle of chlorate of potash or the application of a 
weak solution of nitrate of silver will afford relief. 1006 
SURGICAL DISEASES OF THE MOUTH. 
Atrophic Pharyngitis.-Repeated catarrhal attacks, particularly in persons 
somewhat advanced in life, are calculated to degenerate into a chronic inflam- 
mation of the pharynx, and, being attended by the gradual disappearance of 
the submucous connective tissue, have been called atrophic pharyngitis. The 
mucous membrane will be seen to be dry, red, and polished or glazed, without 
any appearance of secretion. The patient complains of dryness of the throat 
and soreness after talking or in swallowing. 
The disease admits only of palliation, which is obtained by the use of 
cubebs, both internally and topically. The remedy is most conveniently ad- 
ministered in the form of the fluid extract, given with a little syrup of Tolu 
and wild cherry. The local application is best made by inhalation, pouring 
for this purpose some boiling water over powdered cubebs placed in a tin 
vessel, and drawing the vapor into the throat through the neck of a funnel 
reversed and placed over the cup. A lozenge composed of muriate of am- 
monia and extract of liquorice allowed to dissolve slowly in the mouth, at 
the same time swallowing the saliva, will also conduce to the comfort of the 
patient. As such persons often sleep with the mouth open during the night, 
thus increasing the dryness by evaporation, Cohen has advised the use of a 
bandage with which to secure together the jaws. 
Follicular Pharyngitis, sometimes called granular sore throat, is an exceed- 
ingly common affection in the United States. Writers recognize two forms 
of the disease, the hypertrophic and the exudative. 
It begins as an ordinary pharyngitis or tonsillitis, which, from repetition, 
neglect, failing health, or pulmonary disease, merges into a chronic form of 
inflammation, which at length extends from the surface into the follicular 
portion of the mucous membrane, and causes, by infiltration, thickening or 
hypertrophy of the glandular elements of the mucous membrane. 
In the commencement of the disease the hypertrophied glands appear as 
small points, less than a pin's head in size, and scattered over the posterior 
wall of the pharynx, but in the advanced stage of the affection they increase 
in number and size, until many coalesce, forming numerous elevations or 
ridges of the mucous membrane, separated by depressions occupied by dilated 
veins. The granulations are often covered with tenacious mucus. In the 
exudative variety, the fdlliclcs become surcharged with the perverted secre- 
tion, which, by being retained, assumes a cheesy appearance. These struc- 
tural alterations are not restricted to the posterior wall of the pharynx, but 
ultimately, if not early subjected to treatment, extend to the post-nasal and 
inferior parts of the pharynx, and also to the fauces. Notwithstanding the 
fullness of the veins which is observed in aggravated or protracted cases of 
granular pharyngitis, imparting a blue shading to the mucous membrane, 
the vascularity of the glands is not increased ; indeed, some think it is less 
than normal. The cheesy contents of the follicles consist of disintegrated 
epithelial cells, and sometimes contain hard, white, gritty particles, due to 
the presence of lime-salts. 
Follicular disease of the throat is thought to be quite peculiar to clergy- 
men, and is often attributed to the flexed position in which the head is held 
during preaching, rendered necessary by the habit of delivering sermons 
from the manuscript. It is true that when the head is bent towards the 
breast the walls of the pharynx are relaxed, and consequently their vessels 
are less perfectly supported than when the head is erect during speaking, 
and the explanation is not without some plausibility. But I am of opinion 
that, disconnected with the confinement of the study, with faulty digestion, 
and with the wretched habit of standing uncovered in cemeteries and grave- 
yards during inclement weather, while dispensing the last duties to the 
dead, service at the sacred desk would play an insignificant part in the cau- 
sation of throat disease. Indeed, I do not believe that clergymen as a class, 
or as compared with members of other professions or callings, are in any 
way peculiarly subject to granular pharyngitis. INFLAMMATORY AFFECTIONS OF THE PHARYNX. 
1007 
Treatment.-Both local and constitutional treatment are required for the 
removal of follicular disease of the pharynx, modified according to the form 
of the affection. In the first or hypertrophic variety, any error of diet which 
can be discovered, and which is calculated to disturb the digestion, should be 
corrected, and the bowels, if constipated, regulated by gentle aperients. 
Public speaking, if a part of the patient's duty, must also be discontinued 
for a time; after which local applications must be addressed to the mucous 
membrane, in order to secure the reduction of the thickened glands. For 
this purpose resort may be had to one of four remedies, namely, iodoform, 
the compound solution of iodine, nitrate of silver, or tincture of the chloride 
of iron. The first is applied by adding two grains of iodoform to half an 
ounce of glycerin, and brushing the mixture over the wall of the pharynx 
daily. The compound solution can be used in the same way, but should be 
rendered less irritating, before being applied, by adding to each ounce of the 
solution one drachm of laudanum and thirty grains of pulverized gum acacia. 
The nitrate of silver, when employed, may be prepared in the strength of 
thirty grains to the ounce of distilled water. The tincture of the chloride 
of iron may be brushed on in full strength. 
With these remedies, especially when the general health of the patient is 
impaired, the internal use of a pill composed of iodoform, iron, and quinia 
after each meal will contribute to recovery, to which may be added, when 
circumstances allow, change of air. When the granulations show no disposi- 
tion to yield to the above treatment, they must be attacked by destructive 
cauterization. 
There are two agents employed for this purpose, namely, equal parts of 
chloride of zinc and quick-lime, or caustic soda and quick-lime. The last is 
the least painful and the most manageable. In England it passes under the 
name of the London paste. In using the caustic, a sufficient amount of 
water is added to the powder to form a thin paste, a small portion of which 
is to be applied on the point of a pin to one or two of the granulations for 
tour or five seconds, when the patient should wash away the redundant 
caustic by gargling the throat with water. 
This process can be repeated every four or five days to other follicles 
until all have been destroyed. In the exudative form of the disease it will 
suffice to clear away from the surface of the mucous membrane the adherent 
secretions, and after pressing out from the follicles, with the fingei* or the 
edge of a spatula, any accumulation which may be present, to touch each 
with a crayon of sulphate of copper or nitrate of silver. 
Diphtheritic Pharyngitis is a form of inflammation accompanied by a depo- 
sition of lymph, either in patches or in the form of a membrane, not only 
over the mucous membrane of the pharynx, but also upon the fauces, larynx, 
and adjacent parts. The disease depends on the presence in the blood of 
some subtle organic poison, probably of vegetable origin, generated under 
bad hygienic conditions, and rendered active by atmospheric peculiarities of 
construction. 
The adynamic tendency of the disease is very marked. Diphtheria is by 
many regarded as a variety of croup, of which I shall have occasion to speak 
when considering affections of the air-passages. Children between one and 
five years of age are chiefly the subjects of diphtheria. The disease, in addi- 
tion to attacking the pharyngeal, laryngeal, and nasal mucous membranes, 
tends to implicate the kidneys, and to induce local and even general paraly- 
sis. The false membrane consists in a fibrinous infiltrate, situated in the 
upper layers of the mucous membrane of the throat, having an ashy, some- 
times a yellowish, appearance, and when separated from the surface of the 
pharynx or fauces leaves the mucous membrane red and glazed. 
Treatment.-As the local disease is only the visible manifestation of the 
constitutional infection, remedies applied only to the throat exercise very 
little, if any, control over the disease. 1008 
SURGICAL DISEASES OF THE MOUTH. 
The first duty of the physician in commencing the treatment of diphtheria 
is to ascertain whether the disease depends for its existence on local or on gen- 
eral causes. When several children in the same house, or in the same local- 
ity, alone suffer, while others adjacent are exempt from the affection, it will 
be strong presumption in favor of the former, when the evil should be traced 
to its source, and corrected as far as possible, or the patient removed beyond 
its malign influence. If, on the contrary, the disease is wide-spread, affect- 
ing a large district of country or an entire town, its general or epidemic 
character will be apparent. 
The constitutional treatment which in my own experience has been found 
most beneficial is the bold administration of chlorate of potash, tincture of 
iron, and capsicum, with milk-punch and beef-essence as nourishment. Among 
internal remedies, salicylin, or the salicylate of soda, has been extolled espe- 
cially by Hanou, of Erlangen, though others regard the remedy as of little 
value. Similar differences of opinion exist in regard to the use of carbolic 
acid. The local applications in use are tincture of chloride of iron, nitrate 
of silver, diluted carbolic acid, the steam from slacked lime, alum, tannin, 
and many others. 
Syphilis.-The pharynx, in common with other portions of the body, suffers 
from different manifestations of this disease. Among the secondary accidents 
are erythema, mucous patches, and ulceration. Gummy tumors belong to 
the later or tertiary period, and elect the posterior wall of the pharynx. The 
diagnosis of these affections must rest on the antecedent history of the patient, 
and also on other traces of the disease which will probably be present on the 
body. 
Erysipelatous Pharyngitis.-Tn cases of erysipelas of the head, neck, or 
face, an inflammation of the fauces and pharynx sometimes arises, which, 
from its diffused character and its tendency to infiltrate the submucous tissue, 
has been designated erysipelatous. A similar condition attends aggravated 
or malignant forms of some of the exanthemata, as scarlatina and variola. 
The symptoms are quite unequivocal. The mucous membrane of the fauces 
and pharynx is red, livid, and cedematous; deglutition is painful or impos- 
sible; the swelling may extend to the larynx, accompanied with pain arising 
from spasm, and cause difficulty of breathing, threatening suffocation. The 
tongue becomes dark, and the pulse rapidly fails, and, unless prompt relief is 
afforded, death may take place in a very short time. The inflammatory infil- 
tration extends to the muscular walls of the pharynx and oesophagus, even 
reaching the connective tissue along the line of the posterior mediastinum 
of the chest. 
In one case of the disease which I saw, the inflammation resulted in slough- 
ing, which opened the neck externally. When the swelling encroaches upon 
the glottis, threatening suffocation, the patient may be rescued by a timely 
laryngotomy. 
Abscess and sloughing may be prevented by making free incisions into the 
mucous membrane, and thereby removing tension, as in phlegmonous in- 
flammation of the skin and subcutaneous tissue. In addition to these local 
measures, the patient will require to be supported by rectal alimentation, as 
swallowing under the circumstances becomes impossible. To the nutritious 
enemata brandy and quinine must be added. 
Retropharyngeal Abscess may arise either from constitutional or from trau- 
matic causes. The constitutional causes are disease of the cervical vertebra?, 
inflammation of the post-pharyngeal lymph glands and connective tissue, and 
transmitted syphilis. While no age is wholly exempt from this affection, 
young children, especially those having a scrofulous organization, most fre- 
quently suffer. Traumatic cases arise from various foreign bodies becoming 
impacted in the pharynx. AFFECTIONS OF THE PHARYNX. 
1009 
John Adams* reports two cases in which abscesses formed in consequence 
of fish-bones becoming fastened in the pouch ; and in a paper by Allenf on 
retropharyngeal abscess, thirty-eight cases of the latter are collected oc- 
casioned by different foreign bodies, as pins, bones, sticks, etc. 
met with one case produced by injury to the spine. 
Caries of the cervical vertebrae is much the most fruitful source of this 
form of abscess. 
Signs.-The earliest signs of this abscess are slight soreness of the throat 
and some difficulty in deglutition, in consequence of the diminished mobility 
in the walls of the pharynx. The posture of the head is significant, partic- 
ularly when bone disease exists, as it is then carried in a stiff, erect position, 
often only turning with the body when it is necessary to direct the attention 
to some object on one side. As the tumefaction in front of the spine increases 
unless limited by adhesions, the swelling tends to descend, dissecting the 
posterior wall of the pharynx away from the bodies of the vertebrae; this is 
followed by more or less difficulty in breathing, snoring during sleep, and 
possibly by spasmodic suffocative attacks. The abscess may be placed on 
one side of the pharynx or directly behind the middle of its posterior wall; 
the neck behind the angle of the jaw on the corresponding side is swollen. 
Rigors, followed by a hot skin and febrile disturbance, are generally present 
at some stage of the suppuration. 
Diagnosis.-The gradual progress of the disease, the lameness of the neck, 
the presence of an elastic, probably fluctuating, swelling behind the pharynx, 
determined by the direct application of the finger to the parts, together with 
the difficulty of swallowing and the intermittent attacks of dyspnoea, but no 
loss of voice, make it highly improbable that an abscess of this kind will be 
confounded with either croup or oedema of the larynx. 
Among Alien's cases, mentioned above, was one which had been mistaken 
for syphilitic disease. This error can scarcely occur if proper care is taken 
in the investigation, since in the latter affection there are usually external 
symptoms. 
Prognosis.-The prognosis in retropharyngeal abscess is exceedingly grave. 
When induced by disease of the spine, it is almost always fatal. Of the 38 
cases of this abscess collected by Allen, and to which reference has been 
made, only 3 cases are represented to have recovered. All of Stromeyer's 
cases died. Of the 91 cases of Gautier, 41 perished. Bokai gives a more 
favorable representation, only 11 of his 141 cases proving fatal. All of these 
except 13 were idiopathic. The result is in singular contrast with the ex- 
perience of other observers. 
Syme and Gunther have each given a case of recovery after the discharge 
of portions of the vertebrae. In the one recorded by Gunther,§ the third and 
fourth cervical vertebrae were taken away. 
Treatment.-During the early inflammatory stage of the pharyngitis, by 
free incisions, unloading the submucous tissue of the transudation, an abscess 
may be prevented; but in most instances this opportune moment is allowed 
to pass. In those cases which originate from disease of the cervical ver- 
tebrae, of course no abortive measure of this kind is possible; yet the abscess 
should always be opened at the earliest possible moment after being disr 
covered. 
When the accumulation is large, particularly in the case of children, there 
is considerable risk of the pus entering the larynx during the evacuation of 
the abscess. Various precautions have been suggested in order to prevent 
so grave a casualty. Thus, Sir Astley Cooper and others recommend for the 
purpose the ordinary trocar and canula. Schmidt advises pressing the epi- 
glottic cartilage over the opening of the larynx with the finger simultane- 
* Lancet, June, 1847. 
f New York Journal of Medicine, November, 1857. 
j Philadelphia Medical Times, April, 1875. 
'6 Deutsche Klinik, 1859, p. 34; Cohen, Diseases of the Throat and Air-Passages, p. 242. 
vol. ii.-64 1010 
SURGICAL DISEASES OF THE MOUTH. 
ously with the puncture of the abscess. Others would endeavor to effect the 
same closure of the larynx by flexing the head while the opening is being 
made. Neither of these last two plans is practicable. The contact of a 
finger with the epiglottis would cause so much muscular spasm as to render 
the use of the knife uncertain, if not hazardous, and could not, even if the 
incision was made, be retained long enough to be of use; while the postural 
method would require a stab in the dark. When the abscess is high up, there 
is little ground for apprehending any danger from suffocation ; when it is low 
down, the risk will be diminished by making first a small opening, the head 
and trunk being bent forward and downward immediately afterwards, so 
that the contents of the abscess will gravitate towards the mouth, and, after 
the collection has been well emptied, enlarging the opening, if necessary, 
by a second incision. 
The same advantage would be gained in the case of children by inverting 
the body with the head downward. The instrument required for the opera- 
tion is a sharp-pointed tenotome or bistoury. 
Another plan, and one entirely free from danger, is by the aspirator, and, 
when that instrument is at hand, this should be adopted in preference to 
other means. When, either on account of oedema of the glottis or laryngeal 
spasm, a patient suffering from retropharyngeal abscess is threatened with 
suffocation, laryngotomy should be promptly performed. 
Scalds and caustic agents.-Children sometimes ignorantly take into the 
mouth a boiling liquid, or inhale the steam from a tea-kettle or some other 
vessel, or the same accident happens to adults as a result of the explosion 
of steam-boilers. In a recent accident on the railroad running from Camden 
to Atlantic City by the way of May's Landing, in which the engine attached 
to the second section of an excursion-train ran into the rear car of the first, 
a number of the killed met their deaths by the inhalation of the steam 
which rushed into the telescoped car. Caustic liquids, as aqua ammonias, 
mineral acids, or lye from ashes, are also sometimes swallowed or taken into 
the mouth before the mistake is discovered. The violent inflammation 
which immediately follows the presence of such irritants extends through 
the mouth, fauces, and pharynx, and is followed by a rapid oedematous 
swelling that closes the glottis, and, unless timely relief is furnished, may 
quickly terminate life. 
Treatment.-When the dyspnoea is not alarming, the application of 
leeches to the neck, before and behind the angles of the jaws, followed by 
the external and internal use of ice, may suffice to control the inflammatory 
congestion and effusion; but if there is increasing difficulty of breathing, 
no time must be lost in opening the windpipe and introducing a tracheal 
tube. 
Wounds of the pharynx may be homicidal, suicidal, or accidental, and in- 
flicted by dirks, razors, pistols, or guns. In a number of instances they have 
resulted from the impaction of foreign bodies, as bones, and from the use of 
instruments. When produced by suicidal attempts, they are generally made 
through the neck. A wound from the outside, in order to enter the pharynx, 
must be above the thyroid cartilage in front, and laterally above the level of 
the cricoid cartilage. 
Wounds made with suicidal motives are very often between the thyroid 
cartilage and the hyoid bone, and, when sufficiently deep, penetrate the lateral 
walls of the pharynx, severing sometimes the epiglottic cartilage. An incised 
or a shot wound behind the angle of the jaw, or some distance below it, is in 
a favorable position for opening the pharynx. Pistols are sometimes fired 
into the mouth in attempts at self-destruction. 
The immediate danger in pharyngeal wounds is hemorrhage: if this is 
escaped, the remote evils to be apprehended are diffused suppuration and 
fistula. 
Treatment.-The first duty of the surgeon in a wound of the pharynx WOUNDS OF THE PHARYNX. 
1011 
is to control any hemorrhage which may be present. When inflicted through 
the front of the neck, it is only necessary to close the cervical wound, if in- 
cised, by position; the head being moderately flexed on the breast, and so 
maintained by a night-cap having bands running from its sides to a circular 
strip of roller tied round the thorax. (See Wounds of the Neck, vol. i. p. 
318.) 
Mr. Johnson,* of St. George's Hospital, London, was compelled, in one 
instance, to tie the carotid artery on account of repeated hemorrhages from 
a wound of the pharynx, inflicted through the mouth by the end of a 
parasol. 
I have not found sutures of much value. Incised wounds which open 
the pharynx from the side of the neck should be stitched with the silver 
or the animal thread, the sutures at the same time including the sides of 
the superincumbent soft parts. If the two wounds-that in the tissues of 
the heck and that in the pharynx-are closed separately, the lattei' should 
be stitched with the animal thread; as the silver or silk ligature, instead 
of becoming encysted, or ulcerating its way into the pharynx, gives rise to 
abscess. 
If ligatures are used at all, it will be safer to close the pharyngeal wound 
with the animal thread, and allow that in the overlying soft parts to remain 
unclosed and heal by open granulation. When both are simultaneously 
closed, it is highly probable that the secretions from the pharynx will pass 
through the wound; for I am of opinion that as regards quick reunion, little 
is to be expected from the threads which may be inserted into the walls of 
the pharynx. 
Gunshot wounds of the pharynx received through the neck are necessarily 
followed by the detachment of a circumferential slough, and can only heal 
by open granulation tissue; consequently, artificial closure is not to be 
thought of. 
Shot or punctured wounds of the pharynx inflicted through the mouth 
may penetrate the spine or the cranium, and are usually fatal. 
After arresting hemorrhage and dressing the wound, much depends on the 
after-treatment. For the first four or five days all nourishment should bo 
administered through the bowel, and at the expiration of this time, if the 
patient exhibits no signs of exhaustion, this mode of alimentation may be 
continued for some days longer before the stomach-tube is employed. The 
objection to the early use of the latter is this, that, whether introduced 
through the mouth or through the nose, it will for a time provoke some 
reflex movement in the muscles of the pharynx, which complicates and retards 
the healing. Feeding the patient by means of the tube ought therefore to be 
postponed for several days. 
Fistula is one of the terminations of a wound in the pharynx. It may also 
follow an abscess in its walls, or in the adjacent portion of the neck. A dis- 
tressing case of this kind was under my care in the person of an elderly 
gentleman of this city, in whom the pharynx was opened by the ulceration 
caused by the presence of a malignant growth in the neck. The fistula 
opened immediately above the clavicle, after following a circuitous route. 
Fluids and particles of food passed through the track of the fistula, and gave 
rise to other fistula? in different parts of the neck. 
Treatment.-Should a fistula, the result of a wound or abscess, not close 
after a reasonable time, attempts may be made to effect its obliteration by 
stimulating injections or by cauterization. 
The last, which promises most success, can be made by a delicate canula 
bearing a porte-caustique armed with nitrate of silver, which can be applied 
to the fistula in the walls of the pharynx without touching other parts of 
the false passage. The galvano-cautery has been used with success, applied 
through a hollow canula. In a case which resists other measures, it would 
* Holmes's System of Surgery, vol. ii. p. 457. 1012 
SURGICAL DISEASES OF THE MOUTH. 
be proper to use the oesophageal tube for taking nourishment for some time, 
in the hope that the prevention of the intrusion of any foreign bodies might 
lead to the closure of the fistula. 
Foreign Bodies are occasionally swallowed, either accidentally or intention- 
ally, and, in consequence of their 
size, become impacted in the phar- 
ynx. Among these the most com- 
mon are plates of artificial teeth, 
pieces of wood, bones, nails, etc. 
In one instance reported by Mor- 
ton, a large comb was the intruding 
body. (Fig. 1669.) 
Any substance, large or small, 
which becomes arrested in the 
pharynx, gives rise to local irrita- 
tion, cough, dysphagia, pain, and, 
when the body is large and presses 
strongly against the larynx, to 
dyspnoea, and even asphyxia. 
Treatment.-In many cases the 
foreign body can be best removed 
by passing the finger round it and 
hooking it out. If this cannot be 
done, resort must be had to some 
form of the gullet forceps (Fig. 
1674), which sometimes can be 
used with great precision with the 
aid of the laryngoscope. 
Fig. 1669. 
Comb removed in Morton's case-exact size. 
Cicatricial Stenosis.-The capacity of the pharynx immediately posterior 
to the fauces is liable to become very much diminished from the cicatriza- 
tion following specific ulcerations. I have seen a number of these cases 
produced by syphilitic disease. In all, the posterior pillars of the fauces and 
the soft palate were included in the contraction, materially diminishing the 
space between the arches. In one case 1 found the uvula and velum with 
an elliptical opening and attached to the posterior wall of the pharynx, the 
latter being also puckered or corrugated with seams of cicatricial tissue. 
The opening in the soft palate formed the only connection between the post- 
nasal and the post-faucial division of the pharynx. This condition is followed 
by more or less dysphonia, and some disability in deglutition, with dyspnoea, 
and a predisposition on the occurrence of cold to symptoms not unlike croup. 
The dyspnoea may even proceed to asphyxia and death, as happened in a case 
reported to me, in which the cavity of the pharynx was almost entirely 
closed by crossing and interlacing bands of cicatricial tissue following ex- 
tensive syphilitic ulceration. A severe cold produced a pharyngitis with 
nasal catarrh and with moderate bronchitis, and the excess of mucus from 
these sources becoming entangled in the meshes of the fibrous tissue pre- 
vented the entrance of air. The patient when seen by Dr. J. Wm. White, 
who was in charge, was asphyxiated and moribund. Laryngotomy was 
promptly performed, but the case terminated fatally. 
Treatment.-Pharyngeal stenosis, in my experience, is not benefited either 
by incision or by dilatation ; on the contrary, they are positively hurtful, 
and, unless there is a contraction sufficient to prevent the passage of food, 
instrumental meddling of any kind should be avoided. The best bougie is a 
bolus of food, which, on account of its frequent repetition, will serve to main- 
tain the passage pervious. If the necessity for an operation should arise, 
the excision of a piece from the pillars of the fauces will be preferable to 
making a dilatation. DILATATION OF THE PHARYNX. 
1013 
Dilatation of the pharynx may be either general or local. The former has 
been observed as the result of anaesthesia or paralysis of its walls. Local dila- 
tation is more common. The manner of the formation of these pouches is much 
the same as that of the 
sacculated bladder. The 
sudden lateral impulse 
during swallowing com- 
municated to the pharynx 
at the line of its junction 
with the oesophagus, in 
consequence of the abrupt 
contraction of the diame- 
ters of the gullet at this 
point, associated as it 
often is with a defect in 
some of the muscular fas- 
ciculi of the middle con- 
strictor, causes the mu- 
cous and submucous por- 
tions of the tube to yield, 
and to form a button-like 
pullulation on its side, 
which, under the contin- 
ued repetition of the orig- 
inal cause, finally pro- 
trudes between the mus- 
cular fibres, forming an 
elongated pouch (Fig. 
1670), in shape not unlike 
the sac of a hernia. The 
most dependent portion 
of the diverticulum, or 
its fundus, in well-pro- 
nounced examples of the 
kind, is the largest and 
most capacious part of 
the pouch, the cavity of 
which communicates with 
the pharynx by a com- 
paratively small opening. 
The food may enter this 
diverticulum in such quan- 
tities as to form a consid- 
erable tumor in the neck, 
and, as it is without muscular fibres, and therefore incapable ot contracting 
on its contents, the latter can be displaced only by pressure with the fingers. 
Pressure exerted in this way, and the collapsed state of the sac which fol- 
lows, constitute the best means of diagnosing the existence of such a diver- 
ticulum. The sound can be also employed to verify the continuity of the 
pouch with the pharynx. 
The condition appears to be peculiar to old persons, though, its progress 
being slow, the formation of the pouch no doubt begins in middle life. 
Fig. 1670. 
General dilatation and pouched state of the pharynx. 
Tumors in the pharynx arc exceedingly rare. Mr. Pollock records two 
cases which are in the museum of the College of Surgeons, London, one 
fatty and the other fibrous, both of which had been successfully removed; 
and Mr. Holt* mentions another, fatty in its character, which was taken 
from the pharynx of a man far advanced in life, and who probably, from his 
* Holmes's Surgery, vol. iv. p. 488. 1014 
SURGICAL DISEASES OF THE MOUTH. 
death having taken place suddenly, perished in consequence of the mass 
getting into the vestibule of the larynx. 
A pedunculated tumor of the pharynx, under favorable circumstances, 
might be seized and cut off with long scissors curved on the flat, or it might 
be snared in the loop of a wire ecraseur and severed by this means. 
The danger, when the growth is large, of obstructing the larynx in attempts 
at removal has given rise to the wise suggestion of performing laryngotomy 
and inserting a tube as. a preliminary step to the operation. 
Affections of the (Esophagus. 
Congenital Imperfections of the oesophagus are unusual occurrences. In 
three cases reported by Mr. Holmes,* the oesophagus communicated with 
the trachea, and all ended fatally. Other instances of a similar nature have 
been observed by Houston, Annandale,f and Marsh.J The defect might be 
diagnosed by the suffocation and cough attending sucking, caused by the 
milk entering the trachea. In another case reported by Mr. Holmes, be- 
lieved to be congenital, there was a stricture of the oesophagus, which had 
produced an enormous dilatation of the canal above. The patient lived to 
the age of seventy-four, and died of pneumonia. The ground for supposing 
the stricture to have been congenital was the fact that the man could never 
recollect a time when he bad not difficulty in swallowing, requiring some 
liquid with which to wash the food down, and portions of it frequently re- 
turning into the pharynx or the mouth. 
Malformations of the kind mentioned do not admit of treatment. 
Foreign Bodies frequently lodge in the oesophagus. These bodies vary in 
nature, size, and shape, th-e most common being coins (Fig. 1671), bones, pins, 
needles, artificial teeth on the plate, and solid masses of 
food. These bodies are frequently arrested at the junc- 
tion of the pharynx with the oesophagus, the opening of 
which may be likened to that in which the expanded 
point of a funnel and its neck unite. When the body is 
so large as to press strongly against the posterior wall 
of the trachea, the sense of suffocation is so urgent that 
the patient becomes greatly agitated, instinctively throws 
the head back, grows dark in the face, and struggles in 
a wild and excited manner. I believe this is the only 
accident in which the instinctive efforts of the body tend 
to destruction, throwing back the head increasing the 
danger instead of lessening it, by stretching the trachea 
more forcibly over the impacted body. When the foreign 
body passes on to the thoracic portion of the oesophagus, 
these feelings of suffocation are not present. In what- 
ever part of the gullet the offending substance may be, 
even though it may not be sufficiently large to create 
dyspnoea, there will be a feeling of uneasiness, often 
amounting to pain, aggravated by every act of degluti- 
tion, and often accompanied with the abundant secretion 
of ropy mucus. The magnitude of bodies which sometimes find their way 
through the pharyngo-oesophageal constriction is surprising. A singular 
case, illustrative of the above, I saw with Dr. Stewart, of this city. The 
patient, a German, shortly after eating a quantity of sour-crout at a restau- 
rant, missed an entire set of mounted teeth. He remembered that while 
partaking of his favorite dish he had experienced a scratching sensation, 
which, however, had given him no special uneasiness. On introducing a 
probang along the gullet, the teeth were distinctly felt close to the cardiac 
Fig. 1671. 
A copper penny impacted 
in the oesophagus.-From 
preparation in themuseum 
of the University of Penn- 
sylvania. 
* Diseases of Children, p. 136. f Dublin Hospital Reports, vol. v. p. 310; Cohen. 
J British Medical Journal, November 27, 1875, p. 686. AFFECTIONS OF THE (ESOPHAGUS. 
1015 
orifice. The inflammatory swelling which existed at the time of our visit 
not only prevented the passage of liquids, but rendered any attempt to force 
the foreign body into the stomach unadvisable. The patient died shortly 
after. A drawing from the specimen is given in Fig. 1672. Were another 
case of the same kind to come under my care, I should feel justified in open- 
ing the stomach, dilating its cardiac orifice, and ex- 
tracting the body either entire or by instrument after 
division. As the tube below this point enlarges, the 
foreign bodies will gradually pass on until near to the 
oesophageal opening in the diaphragm, when the canal 
is again constricted. 
Bodies may remain for some time in the oesophagus, 
and be finally dislodged in a fit of coughing or vomit- 
ing. They may also, when pointed, cause ulceration, 
and find their way into adjoining organs or parts of 
the body. Andrews* gives a case in which a fish-bone 
passed through the gullet in this manner, entered the 
heart, and destroyed the patient by hemorrhage. 
Erichsenf mentions an instance in which a piece of 
gutta-percha had ulcerated through the oesophagus, 
and, by opening the oesophageal vessels, caused death 
by hemorrhage. Mr. Kerby, of Dublin, also mentions 
a case in which the patient died from hemorrhage, 
the foreign body, a bone, having perforated the oesoph- 
agus and wounded an abnormally placed subclavian 
artery. Dr. Cohen J met with a case in which a gold 
plate lodged in the tube had caused an ulceration 
into the trachea at its bifurcation, through which 
passed substances which had been swallowed, and 
which were then often ejected from the mouth in a paroxysm of coughing. 
The same writer records also an instance of a man having swallowed, when a 
youth, two peculiar-shaped pins, which, thirty years after, were found lodged 
under the skin of the shoulder. I once removed from the substance of the 
heart of a bullock an eight-penny nail, which, no doubt, had reached that 
organ by way of the gullet. Dr. Ogle, of London, gives a case ending fatally 
in which the medulla spinalis had become diseased from a bone which had 
been lodged in the oesophagus finding its way into one of the intervertebral 
cartilages. 
A strolling juggler was carried in a state of fatal collapse into the University 
College Hospital, London. This man, while amusing a street crowd by the 
feat of swallowing a sword, gave the weapon a forcible push at a point where 
it became arrested near to the root of the neck, and was seen suddenly to 
withdraw it, leap spasmodically into the air, and fall to the ground in a faint. 
After his death the point of the sword was found to have penetrated the 
oesophagus and entered the pericardium, though neither the heart nor any 
of its vessels were injured. 
Treatment.-When a foreign body of a size calculated to give rise to 
symptoms of suffocation becomes arrested in the oesophagus, much may be 
accomplished to relieve the urgent sensations by keeping the head of the 
patient bent forward, and at the same time allaying his or her fears by a few 
words of encouragement until the means necessary for the extraction of the 
body can be obtained. The only domestic remedy-a good thump on the 
back-is not to be despised, and has in many instances dislodged from the 
throat of a child a piece of meat or other substance which had become arrested 
at the top of the gullet. The particular instrument best adapted to extract 
a foreign body will depend altogether on the character of the latter. A pin, 
Fig. 1672. 
Plate of artificial teeth in 
the oesophagus. 
* London Lancet, 1860. 
f Erichsen's Surgery, vol. ii. p. 484. 
j Diseases of the Throat, etc., page 313, 2d ed. 1016 
SURGICAL DISEASES OF THE MOUTH. 
needle, or splinter can often be removed by the forceps of Bond. (Fig. 1673.) 
The blades of this instrument are wedge-shaped, and the summit of each 
Fig. 1673. 
Bond's gullet forceps. 
blade is serrated. The mechanical advantage of this arrangement consists in 
the tendency of the body, when caught, to turn in a direction parallel with 
the blades of the instrument, and thus be more easily extracted. Coins, 
pieces of bone, and mounted artificial teeth are most readily seized and re- 
moved by forceps fashioned like that represented in Fig. 1674, or by means 
Fig. 1674. 
Gullet forceps. 
of the swivel. (Fig. 1675.) A body which is fixed in the oesophagus cross- 
wise may sometimes be detached from its position by a blunt hook passed 
Fig. 1675. 
(Esophagus swivel. 
beneath one of its ends and retracted, after which the forceps can be employed 
for its removal, or it may be ejected by the efforts of the patient. 
Fig. 1676. 
Horse-hair snare, closed and open. 
When both these devices are unsuccessful, the horse-hair snare (Fig. 1676) 
will often accomplish the object. 
The instrument closed, and its extremity oiled, is passed down along the AFFECTIONS OF THE (ESOPHAGUS. 
1017 
oesophagus below the point of obstruction, when it is expanded, the hair 
forming a kind of parachute, in which state it is to be withdrawn, when the 
entire circumference of the gullet will be swept. 
An ingenious method for extracting a fish-hook to which a portion of the 
line was attached, and which had become fixed in the oesophagus, was de- 
vised by Dr. Bright, of Kentucky. The line was passed through a perforated 
bullet, and as the latter passed down the cord the hook was disengaged by 
the momentum and weight of the lead, and successfully removed. 
Bodies whose exterior is round and free from points and angles, and which 
cannot be extracted, maybe safely pushed into the stomach. Masses of food 
which become arrested from being disproportioned to the capacity of the 
tube may be treated in the same way. 
The sponge probang (Fig. 1677) is best adapted for this purpose. In either 
Fig. 1677. 
Sponge probang. 
withdrawing foreign bodies from the oesophagus or pushing them down, no 
unnecessary force or rude manipulation should be practiced, as irreparable 
injury may be done to the tube in this way. 
In a few cases of bodies impacted in the cervical portion of the gullet, 
oesophagotomy may be required. Pins, needles, coins, bullets, and various 
indigestible substances are often swallowed by children, and are either tem- 
porarily arrested in the gullet or pass straight on into the stomach. These 
are seldom followed by any evil consequences. The treatment in cases of 
this kind has been given under the head of foreign bodies in the stomach 
(vol. i. p. 392). 
Wounds of the oesophagus are sometimes produced in attempts at suicide 
by cutting the throat. The tube may be opened by a stab in the neck. I 
have known the accident to occur in an attempt to pass an instrument 
through a stricture. Rupture of the oesophagus has followed during vomit- 
ing. Two cases of the kind are noted by Durham,-one related by Boerhaave, 
that of a prominent baron, who, being greatly addicted to the pleasures of 
the table, was in the habit of voluntarily exciting vomiting in order to avoid 
the evil effects of such indulgence. In one of these efforts he was attacked 
with great distress in the chest, and shortly after died. The oesophagus, on 
examination, was found torn. The other case was reported by Dr. Griffin, 
in the Lancet for September 4, 1869. Dryden and Gramatzki each give an 
instance of rupture following a drunken excess, and Mr. Adams* has recently 
reported an accident of the same nature. The patient had been a gouty, 
dyspeptic subject. Shortly after eating a quantity of beefsteak, he was at- 
tacked with pain and retching, becoming pale, and passing into a state of 
collapse. Death followed in eight hours, and on examination the oesophagus 
was discovered to be ruptured immediately above the diaphragm, and the 
contents of the stomach lying in the left pleural cavity. A piece of hard 
gristle which had been swallowed was supposed to have been the cause of 
the lesion. In all these cases there was probably some degeneration of the 
muscular walls of the tube. 
* British Medical Journal, June 15, 1878, p. 865. 1018 
SURGICAL DISEASES OF THE MOUTH. 
Treatment.-It is only when the lesion occurs in the neck that surgical 
measures are practicable. The great danger is hemorrhage from the large 
vessels of this region, which often proves fatal before aid can be obtained. 
The duty of the practitioner is first to secure all bleeding vessels, and then 
to bring the edges of the oesophageal wound together with interrupted su- 
tures, using for the purpose the animal thread, and leaving the wound in the 
superincumbent soft parts open, as in like injuries of the pharynx. 
Fistula.-Fistulous openings in the neck communicating with the oesopha- 
gus are occasionally observed, both congenital and acquired. 
Acquired fistula is among the sequels of wounds of the oesophagus, and 
is exceedingly intractable to treatment. The external openings appear 
usually in the neck, and often follow quite a circuitous course, opening upon 
the surface at some point remote from where the communication with the 
oesophagus exists. An oesophageal fistula is recorded by Coghill* which 
opened through the parietes of the chest, following what was supposed to be 
pleurisy, accompanied by congestion of the lungs. 
The escape of alimentary substances, both solid and liquid, through the 
external opening establishes the diagnosis of oesophageal fistula. 
Treatment.-Injections of the fistulous track with solutions of the sul- 
phate of copper and nitrate of silver, which are recommended, promise very 
little success. Cauterization by nitric acid applied by means of a silver probe, 
equivalent to the use of nitrate of silver, or the galvano-cautery, will give a 
better result. But when the sinus is direct,-which can be determined by 
the probe,-or even when indirect, laying the entire length of the track 
open and commencing anew the work of repair offers the best chance for a 
cure. 
This operation is a delicate one, and for its execution requires that a fine 
probe be passed along the fistula as a guide for the incisions, which arc to be 
made with due consideration for the vessels that may be encountered. If 
the course of the fistula is tortuous, so that the probe can traverse only a 
small extent of the abnormal channel, the latter should be divided to that 
extent, when a way will be opened foi* a second introduction of the guide, 
and so on until its internal orifice has been reached. Other methods should 
always be tried before resorting to such an operation, which requires ex- 
ceptionally accurate anatomical knowledge. The wound, after incision, must 
be treated on the same principles as when made for fistula? in other parts of 
the body, namely, by introducing a pledget of lint and allowing it to close 
by granulation tissue. 
Retro-oesophageal Abscess.-A retropharyngeal may become a retro-oeso- 
phageal abscess by simple extension, the matter dissecting its way down into 
the neck. When the abscess is independent of such an origin, it may arise 
from disease of the cervical or dorsal vertebra?, from stricture of the oesoph- 
agus, or, as in one of my own cases, from a malignant growth of the larynx. 
Symptoms.-When the abscess is an extension from the postpharyngeal 
region above, the larynx will be prominent in common with the trachea, and 
the swelling will be chiefly on the right side, in accordance with the position 
of the oesophagus. The trachea will also be thrust over towards the left side, 
and the head inclined forward in order to relax the air-tube and lessen the 
difficulty of breathing. The voice, according to Duparcque, is also diag- 
nostic, being shrill and piping. Deglutition is not altogether impossible, 
though the fluids which are taken may be detained for a few moments before 
passing down. Should they regurgitate, they are liable to enter the larynx. 
Retro-oesophageal abscess, when it occurs within the thorax, must take 
place somewhere above the ninth dorsal vertebra. It is almost always 
among the secondary effects of caries of the dorsal vertebra?, though it may 
follow traumatic causes, as the use of the probang or the impaction of false 
* British Medical Journal, July 20, 1877, p. 68. AFFECTIONS OF THE (ESOPHAGUS. 
1019 
teeth. When the result of spinal disease, it constitutes spinal abscess, and 
only when, as is sometimes the case, the pus finds its way to the loin or the 
groin can it be diagnosed. 
Treatment.-Should the breathing become so difficult as to threaten life, 
tracheotomy will be demanded, and ought not to be too long delayed. If 
the signs of the abscess arc sufficiently clear, a formal dissection of the neck, 
as in oesophagotomy, should be unhesitatingly performed with a view to open 
a way for the escape of the pus. 
Stenosis.-Narrowing of the canal of the oesophagus arises from two general 
sets of causes,-extrinsic or functional and intrinsic or organic. The extrinsic 
may be divided into mechanical and reflex or spasmodic. The former are 
enlargements of the lymphatic glands of the neck or the bronchial glands in 
the thorax, retro-oesophageal and perioesophageal abscess, aneurism of the 
carotid or of the innominate artery, malignant growths in the neck or 
within the thorax, and, in rare instances, dislocation of the sternal extremity 
of the clavicle. 
Many of the causes are not susceptible of being removed, for example, 
malignant intrathoracic or cervical growths. Whenever the cause falls 
within the pale of operative or therapeutic measures, the relief of the stenosis 
is insured. 
Reflex stenosis will be considered under the head of neuroses of the 
oesophagus. 
Intrinsic or organic stenosis (stricture) depends on a structural alteration 
in the walls of the gullet, not only destroying the dilatability of the tube, 
but also narrowing its canal. 
The most common among the causes producing this form of stenosis are 
carcinoma and cicatricial contraction from caustic alkalies and acids. Indeed, 
the former outnumber all other causes combined. Carcinoma, which is always 
epithelial, is most frequently located somewhere in the last four inches of the 
oesophagus. In the cases collected by Peter, Zen- 
ker, and Ziemssen, amounting to twenty, 14 were 
in the lower and middle portions of the tube, 4 
in the middle, and 2 in the upper third. In rare 
cases the disease has been seen to involve the 
whole length of the gullet. Professor Harrison 
Allen,* who has analyzed a considerable number 
of oesophageal obstructions from different causes, 
regards the portions of the tube most liable to 
pathological or mechanical stenosis as the part 
behind the cricoid cartilage, and that which is 
crossed by the left bronchus. 
The infiltration which begins in cancer in the 
submucous tissue of the canal gradually extends 
to all its coats, until not only docs it encroach 
on the interior of the tube, obstructing its cavity, 
but at length forms a large mass externally. (Fig. 
1678.) Elderly persons are usually the subjects 
of oesophageal cancer. Females are said to suffer 
more frequently than males; but according to 
my observation the disease is equally common 
in both sexes. 
When the stricture is produced by caustic 
agents, it must be referred to the new connective 
tissue which takes the place of the destroyed 
mucous and submucous components of the tube, 
and the contraction of which causes the narrow- 
ing; and the same is true of those coarctations which follow the healing of 
Fig. 1678. 
Carcinoma at the lower part of the 
oesophagus. 
* Localization of Diseased Action in the (Esophagus. 1020 
SURGICAL DISEASES OF THE MOUTH. 
syphilitic or other ulcerations of the oesophagus. The subjects of this variety 
of stenosis are children or persons in middle life. 
The obstacles offered to the passage of food in the two classes of cases, 
namely, the carcinomatous and the cicatricial, are, therefore, unlike; in the 
former it is obstructed by the growth of the tumor, involving or destroy- 
ing most of the coats of the tube, while in the latter the canal is lessened 
by the contraction of its own walls: hence the term organic stricture should, 
strictly speaking, be applied only to stenosis from cicatricial causes. In 
both cancerous and cicatricial cases, however, two obstacles to the transmis- 
sion of the bolus of food along the gullet are always present, namely, dis- 
ability from the failure of peristalsis, and the loss of the proper lubricating 
fluid. 
Stenosis exists in all degrees, from the slightest narrowing to almost com- 
plete closure. The form of the contracted orifice is sometimes angular, and 
at other times irregularly oblong or fissure-like. 
Symptoms.-The earliest symptom of oesophageal stenosis is some imper- 
fection or disturbance in deglutition. The difficulty is first observed in swal- 
lowing solids. There is a brief interruption in the passage of the bolus; it 
sticks, not so much from the diminished calibre of the canal as from the 
impaired capacity of the circular and longitudinal muscles to effect the 
physiological modifications in the length and diameter of the tube. As the 
morbid process progresses, increasing the narrowing or obstruction, the dif- 
ficulty of deglutition is often accompanied with a feeling of uneasiness, pain, 
and constriction in the chest, with occasional attacks of dyspnoea and eructa- 
tions of wind. Often the food, after sticking fast for a short time, is re- 
turned into the pharynx, when a second effort will be made to swallow it. 
If the stenosis is seated low down, a considerable quantity may accumulate 
in the gullet, and remain, perhaps, days before being regurgitated, and even 
then the substances may be again swallowed before reaching the pharynx. 
The resistance which the food encounters at the seat of coarctation, with 
the constant repetition of the peristaltic power in swallowing, often causes 
the oesophagus to become greatly dilated or expanded above: in one case 
that I examined after death, this pouch rivaled the stomach in size. 
Sometimes the arrest provokes vomiting, and the contents of the stomach 
are ejected along with the oesophageal accumulations. After a time solids 
are entirely discarded, and liquids, which in the early history of the case pass 
along the tube without being delayed, are alone used, and these finally are 
arrested, but gradually trickle through. The difficulty experienced in taking 
a sufficient amount of nourishment soon begins to tell on the patient. The 
strength fails, the flesh wastes, and, in malignant stricture, the color of the 
face reveals the deadly nature of the affection. When the stenosis is the 
result of caustic agents, the stricture is often very irritable, the contact of 
the blandest food, solid or liquid, being quite sufficient in some instances to 
excite spasmodic contraction of the gullet and the violent expulsion of its 
contents. In addition to the symptoms already given, there are others which 
have been noted, as the scaphoid form of the epigastrium and the sunken 
appearance of the left hypochondriac region. 
Auscultation and percussion have been employed in cases of oesophageal 
stenosis. Hamburger, whose name is most prominently associated with the 
method, attaches much importance to the evidence which may be gained by 
applying the car to the left side of the spine, at any point between the fifth 
cervical and the eighth dorsal vertebra. When a liquid is passing through 
a healthy gullet, the gurgling sound of the fluid can be distinctly heard. It 
is alleged that when a stricture exists this characteristic noise will cease, or 
will be lessened in intensity, at a point corresponding to the narrow portion of 
the oesophagus. To my own ear, when I have tried it in cases of this nature 
in order to verify the claims made for auscultation, the result, I must say, has 
been negative, although it is possible a larger experience may compel me to 
modify this statement. AFFECTIONS OF THE (ESOPHAGUS. 
1021 
Diagnosis.-As oesophageal stricture may be closely imitated by nervous 
disturbances of the tube from hysteroidal or psychical states, it is important 
that no mistake should be made in this particular. The reality of the stenosis 
will often be apparent on inquiry, there having been a history of injury to 
the oesophagus from the accidental swallowing of some caustic material. In 
narrowing from external pressure or from organic change in the tube, the 
difficulty in deglutition will have been progressive. Moreover, the loss 
of flesh and strength, and the pinched, wan, and anxious cast of the face 
which attend the imperfect nutrition of the body, are not seen in stricture 
which arises from emotional causes. 
When the diagnosis is obscure, the use of the oesophageal bougie will serve 
to solve the difficulty. For this purpose a long rubber catheter or bougie, 
with olive-shaped extremity, should be passed, after the manner to be pres- 
ently described, or, should one possessed of more firmness be necessary, a 
whalebone instrument can be employed. 
The diagnosis of the stricture being established, it is important to ascertain 
the nature of the cause. We have already observed that a very large pro- 
portion of all cases of oesophageal stenosis are from cancer. If, therefore, 
the stricture occurs in a patient who has passed the meridian of life, or who 
is aged, the probabilities are largely in favor of its cancerous origin, and if, 
in addition, the person is losing flesh and has a cachectic appearance, the 
evidence will amount almost to certainty. 
When the stenosis is caused by external pressure, a careful inquiry into the 
antecedent history of the case will become necessary in order to form any 
just idea on the subject of causation. If it arises from the pressure of an 
aneurism, there will be the characteristic bruit, and possibly an external 
tumor, both of which signs will probably have been recognized before the 
oesophageal symptoms appear. 
Spinal or retro-oesophageal abscesses wfill generally have been revealed by 
pre-existing signs of caries and symptoms of hectic. 
Syphilitic stenosis is a disease of middle life, and may be suspected if the 
patient has been the subject of previous specific lesions. 
Prognosis.-Organic stricture of the oesophagus is an incurable affection, 
and even when the stenosis is due to mechanical pressure it will often admit 
only of palliation. When due to malignant disease, life is seldom prolonged 
beyond one or two years; though I have a gentleman under my care who has 
survived five years. Stricture from caustic agents, if the patient escapes the 
immediate dangers of inflammation and is of tender years, may not mate- 
rially shorten life. 
Treatment.-The treatment of oesophageal stenosis demands the greatest 
care and sound judgment. It is mechanical and medicinal. 
The indiscriminate use of bougies has done, and is calculated to do, an 
immense amount of harm. When the obstruction has been traced distinctly 
to a malignant cause, the use of bougies should be discarded. I am fully 
convinced that in such cases instrumentation of any kind is an unmitigated 
evil. Bougies, under these circumstances, provoke irritation and swelling, 
and excite a more rapid growth in the neoplasm. The proper course to 
pursue in malignant cases is to support the patient on liquids, as milk, animal 
broths, and gruel. 
No stimulants should be taken by the mouth, and when from any cause 
there occurs a temporary narrowing of the stricture from congestion or spasm, 
the nourishment should be administered altogether by the rectum, while at 
the same time a mixture of the bromide of potassium and tincture of bella- 
donna is exhibited internally until the swelling subsides. I feel confident 
that by pursuing a course of this kind the comfort of the patient will be 
best secured and life will be prolonged. 
When the occlusion of the oesophagus is the result of external pressure, 
the tube itself being sound, and when, in consequence, a serious impediment 
is offered to the passage of food, nourishment can be introduced into the 1022 
SURGICAL DISEASES OF THE MOUTH. 
stomach by carefully passing the oesophageal tube, which, except in extreme 
cases, can be done without any great difficulty. 
It is in cicatricial stricture that the use of bougies finds its proper applica- 
tion, and even here the nice point to determine is just how often their intro- 
duction should be practiced. It has occurred to me to have an unusual 
number of cases of cicatricial stenosis, especially among children, the class 
of persons most commonly affected, and as my experience extends I find a 
growing disposition to lengthen the time between the periods of dilatation, 
rarely deeming it necessary to introduce a bougie oftener than once in four 
or five days; the intervals should usually not be longer than two weeks. 
It is best to commence the dilatation with a gum bougie, and after the 
stricture has become accustomed to the contact of the soft instrument the 
latter should be substituted by one constructed entirely of whalebone, very 
flexible, and with olive-shaped extremities of graduated sizes (Fig. 1679), or 
the extremities may consist of ivory or hard rubber, securely riveted or, what 
is better, screwed to the end of the whalebone. (Fig. 1680.) This last pre- 
caution is one of importance, as I have known the extremity to come off 
Fig. 1679. 
Author's whalebone bougie in one piece. 
while being used and to remain in the oesophagus. Nothing is to be gained 
by forcible measures. The dilatation must be carried on patiently, increasing 
very gradually the size of the bougies. 
Fig. 1680. 
Bougies with hard-rubber extremities. 
Belladonna will be found a valuable adjuvant in these cases, rendering 
the stricture more tolerant of the instrument and preventing spasm of the 
oesophagus. 
Strictures arising from syphilis yield to large doses of the iodide of potas- 
sium. 
The introduction of bougies, probangs, etc., into the oesophagus should 
always be done with the patient in the sitting posture. The objection to 
attempting this procedure while the person is lying down is not only the 
inconvenience of the position, but the risk that in case any matters should 
be vomited they might enter the larynx. With children who are timid and 
struggle, the operation will be facilitated by a few inhalations of chloroform 
or a slight etherization. 
The mouth being opened and the jaws kept asunder by a piece of soft 
wood or a cork with a string attached, inserted behind the molars of the 
upper and lower maxilla?, and the head thrown well back to bring the fauces, 
pharynx, and larynx approximately on a line, the instrument, previously 
well oiled, is carried directly back until the posterior wall of the pharynx is 
touched, along which, the handle being raised, the bougie, sound, or probang, 
as the case may be, is to be pushed onward into the oesophagus. This canal 
being reached, the future management of the instrument must be determined 
by the object in view, whether that is the extraction of a foreign body, the 
dilatation of a stricture, or the introduction of fluids through the stomach- 
tube, never forgetting that no undue force is allowable, especially when the AFFECTIONS OF THE (ESOPHAGUS. 
1023 
tissues of the gullet are altered by disease, thus endangering perforation of 
its walls. 
When any apprehension is entertained of the instrument slipping into the 
larynx, the possibility of such an accident may be prevented by passing the 
index finger of one hand over the root of the tongue until it touches the 
epiglottis. Then with the other hand the instrument is passed over the 
finger as a guide beyond the opening of the larynx, the tongue being at the 
same time dragged forward so as to increase the space between the larynx 
and the posterior wall of the pharynx. 
In non-malignant cases of stricture, where all attempts to pass the obstruc- 
tion have failed, and where no liquids can be swallowed, oesophagotomy will 
be justifiable when the stricture is opposite to the cricoid cartilage; when it 
is below the neck, even gastrotomy becomes proper in some cases. 
Pharyngo-(Esophageal and (Esophageal Pouches, or Diverticula, are also 
among the affections of the gullet. They arise both from mechanical and 
from pathological causes. Possibly there may be a congenital diverticulum. 
Those of the first variety are almost always found at the junction of thepharynx 
and the oesophagus, and belong, therefore, more strictly to the former than 
to the latter.. They include only a small portion of the circumference of the 
pharynx, but may become elon- 
gated into pendent, pyriform sacs, 
which hang down between the 
oesophagus and the spine, and by 
their size not only divert the food 
from the main channel, but also 
by pressure constitute an obstacle 
to the passage of the aliment 
which may take the proper route. 
(Esophageal diverticula, like the 
pharyngeal, are destitute of a mus- 
cular coat, although a few strag- 
gling fibres may be seen over their 
walls. (Fig. 1681.) 
Sometimes the dilatation of the 
oesophagus is general, and accom- 
panied with an unusual develop- 
ment of the muscular layers of the 
tube, as in the remarkable case of 
Luschka (Fig.1682),which appears 
to have existed from early life, 
and to have been attended with 
disease of the stomach and carci- 
noma of several thoracic glands. 
The pathological diverticula are 
found, for the most part, in that 
part of the tube which lies behind 
the commencement of the bron- 
chial tubes, and were first de- 
scribed by Rokitansky.* The for- 
mation of these lateral pouches is 
due to inflammatory degenerations 
and shrinking of the bronchial 
glands which lie in contact with the external surface of the oesophagus in 
the locality specified, and the resulting contraction of the connective tissue 
which remains. These little pouches sometimes consist of all the layers of 
the oesophagus; at other times, of the mucous and submucous coats alone. 
The manner in which the wall of the tube is drawn out gives to the mucous 
Fig. 1681. 
(Esophageal diverticulum.-From a specimen in the museum 
of the College of Physicians. 
*■ Handbuch der Patholog. Anat., vol. iii. p. 160. 1024 
SURGICAL DISEASES OF THE MOUTH. 
membrane a plicated appearance, the folds radiating from the summit of the 
sac towards its circumference. 
We have no means of diagnosing the existence of these pouches during 
life, unless, as sometimes occurs, ulceration takes place, opening a communi- 
cation between their orifices and the bronchial tubes, forming broncho-oeso- 
phageal fistula); the appearance in the expectoration of alimentary substances, 
which could have entered the bron- 
chial air-passages only by way of 
the oesophagus, renders a diagnosis 
possible. 
Prognosis. - A diverticulum of 
large size may be followed by the 
same evil as stricture; that is, it may 
prevent the food from passing into 
the oesophagus and eventually bring 
about death from starvation. It 
might be supposed that such a ter- 
mination could be prevented by the 
use of the oesophageal tube ; but this 
may be entirely defeated by the 
flexion produced in the oesophagus 
by the pressure of the pouch, and 
only when the latter was empty 
would the passage of an instrument 
be possible. 
Treatment.-Some assistance the 
patient can render himself by sub- 
sisting principally on liquids, and by 
making pressure on the diverticulum 
simultaneously with deglutition. 
When these measures prove of no 
value, and the danger of irritation 
becomes imminent, the gravity of 
the case justifies an operation. I 
am not aware of any such having 
as yet been performed. The steps 
of the procedure would consist in 
exposing the pouch in the neck, and, 
after isolating it from all adventi- 
tious connections, ligating its neck 
and cutting away the remaining por- 
tion a short distance from the liga- 
ture. Until the threads come away 
and the opening is closed, no vol- 
untary deglutition would be admis- 
sible, the patient being nourished 
either through the rectum or through 
the oesophageal tube. 
Varices.-In the submucous tissue of the oesophagus are sometimes seen 
dilated veins which impart in places a blue appearance to the lining mem- 
brane. These veins belong to those which surround the oesophagus. The 
varices occur in old persons. They sometimes give way, and thus constitute 
one of the sources of oesophageal hemorrhage. A very ingenious explana- 
tion of the tardy appearance of dropsical effusion, which is occasionally 
witnessed in certain diseases of the liver, has been given, founded on the 
connection which exists between the portal system and the oesophageal and 
azygos veins through the gastric vein, and which serves to relieve the 
portal vessels of a certain degree of distention. The existence of varices 
Fio. 1682. 
General dilatation of the oesophagus. MORBID GROWTHS OF THE (ESOPHAGUS. 
1025 
might be suspected in a case of oesophageal hemorrhage by proceeding on 
the principle of elimination, but the diagnosis would be altogether prob- 
lematical. 
Morbid Growths of the (Esophagus. 
With the exception of carcinoma, morbid growths are very rarely met 
with in the oesophagus. Fibromata and myomata have, in a few instances 
only, been discovered in this locality. 
Carcinoma, as has been observed in connection with stricture of the gullet, 
is confined chiefly to the lower portion of the tube, and is never seen except 
in the form of epithelioma, taking its origin in the deeper layers of the mu- 
cous membrane. The earliest evidence of its presence is the dysphagia 
incident to the obstruction of the tube, and its tendency is always to a fatal 
termination. During its progress secondary deposits of the disease are liable 
to occur in the liver, lungs, and bronchial glands, less frequently in the other 
viscera or organs. 
Fibromata, or Polypi.-These growths, from their pedunculated form, are 
found hanging into'the oesophagus, but their attachment is almost always at 
the lower part of the pharynx. The tumor is generally solitary. In one 
case, that noted by Sir Charles Bell, a number of these bodies were found 
clustered together both above and below the pharyngo-oesophagcal junction. 
Their pendent position, aided by the pressure of the aliment in descending 
the gullet, tends to increase their growth in a longitudinal direction. In one 
instance mentioned by Rokitansky the polypus had attained the length of 
seven and a half inches. 
Although these growths extend into the oesophagus, they are not always 
accompanied by dysphagia, and hence they may exist a long time without 
being suspected, and, being in a position to escape observation, their diag- 
nosis is uncertain. They have been occasionally forced into the pharynx 
during the efforts made in vomiting, and in this way have been recognized. 
When in addition to dysphagia there is dyspnoea, the latter occurring 
after vomiting, and in a male patient,-men suffering oftener from these 
growths than women,-and there is no history of stricture, the existence 
of a polypoid growth may be suspected. In formidable cases these tumors 
have been removed. The method of performing an operation of this kind 
would be, when the growth was attached by a narrow stalk and accessible, 
to seize the body of the tumor with a pair of polypus forceps and twist 
it away from its attachment, or to snare it with the wire noose of a double 
canula and destroy it by strangulation. The operation should never be 
undertaken unless the surgeon is prepared, in case the emergency arises, 
to open the larynx. Where life is seriously imperiled by a neoplasm of this 
kind, the attachment of which can be located at an accessible point with a 
reasonable degree of certainty, and where other methods are not available, 
the surgeon is justifiable in resorting to oesophagotomy. 
Sarcoma, like fibroma, when occurring in the gullet, has fixed on the re- 
gion where the pharynx and the oesophagus join. Being seated at the nar- 
rowest portion of the alimentary tube, with no tendency to become pedun- 
culated, the obstructive effects of the disease soon become very marked. 
Dr. Chapman* met with a case of this kind. 
The disease does not admit of any radical treatment. 
Parasitic growths of vegetable origin have frequently been met with ad- 
herent in patches to the mucous lining of the oesophagus, and in a few in- 
stances, as in those reported by Virchow and Buhl, even filling up the entire 
tube and causing death by obstruction. These masses consist of a net-work 
* American Journal of the Medical Sciences, October, 1877. 
VOL. IT.-65 1026 
SURGICAL DISEASES OF THE MOUTH. 
of filaments (the oidium albicans), and are identical in character with those 
fungi found in the mouth which give rise to thrush. 
Letzerich has described a parasitic growth which he detected in the oesoph- 
agus of a child, and which was made up of micrococci imbedded in the oeso- 
phageal mucus, they having reached their new habitat by being transferred 
from portions of wall-paper which the child had scraped from the room and 
carried to her mouth. The microscope alone could reveal the existence of such 
growths in the discharges from the gullet, and when discovered the internal 
use of salicylic or carbolic acid would be indicated. 
Spasm.-Spasm of the oesophagus (oesophagismus) is characterized by a 
sudden partial or complete inability to swallow, accompanied by a feeling of 
constriction, pain, and glowing heat in the chest or neck. In the attempt 
at deglutition, the food, when the spasm is seated in the cervical portion of 
the tube, is often returned into the mouth, or, if the obstruction is in the 
thoracic portion, rumination will be incomplete, the substance rising and 
again being swallowed. These attacks are liable to be provoked under very 
different physical conditions. Thus, with some persons hot liquids, and 
with others cold, will excite a spasm. A paroxysm is often induced under 
emotional influences, as joy, grief, surprise, anger, etc. The globus hystericus 
is attributed by some writers to this cause, the feeling of the ball rising upward 
to the throat being supposed to depend on a reversed peristalsis of the mus- 
cular fibres of the oesophagus. No such action, however, has as yet, I believe, 
been demonstrated to occur in these muscles: so that the explanation is en- 
tirely a hypothetical one. Women are more subject to these spasmodic 
attacks than men ; even childhood is not entirely exempt from the affection. 
The spasm may be transient, affecting the tubes for a few moments, or it 
may last for hours, days, or weeks. A few rare cases have been recorded in 
which the disease continued for years,-in one instance fifteen years, and 
in another thirty years. 
The pathology of oesophageal spasm is obscure, but there are strong reasons 
for believing that the affection is always the result of irritation acting di- 
rectly on the peripheral loops of the pneumogastric nerves, or reflected from 
other nerves to the latter, or, finally, transmitted from central irritations, 
physical or psychical. 
Diagnosis.-The diagnosis of spasmodic stricture is sometimes quite em- 
barrassing. The functional nature of the affection can only be positively 
established after a careful inquiry into the history of the case, aided often by 
an instrumental examination. In conducting an inquiry of this kind, the 
first consideration would be the sex of the patient, oesophageal spasm being 
almost peculiar to females. Second, the constitutional temperament. An 
emotional woman whose antecedent life had been characterized by nervous 
disturbance of different kinds would, on this account, be a favorable subject 
for spasm. Third, manner and circumstances of attack. Was the invasion 
sudden, and not introduced by a considerable period of prodromes, and was 
it preceded by any physical or mental excitement calculated to disturb the 
nervous system? These are very important questions, as organic stricture 
and its effects are progressive, not sudden, and arc not likely to follow some 
wave of temporary feeling or excitement. Fourth, the duration of the attack. 
Spasmodic coarctation of the oesophagus often leaves as suddenly as it comes 
on, and a considerable interval may intervene before a second attack is ex- 
perienced. When a physical exploration is made of the oesophagus, and the 
sound encounters the stricture, if the latter is spasmodic the spasm will prob- 
ably be intensified; but if the point of the instrument is allowed to remain 
for a short time in gentle contact with the contracted part of the tube, 
without any effort to force a passage, the walls will be found presently to 
relax, and in.a.little while will allow the bougie to pass without resistance. 
Neurosis of the (Esophagus. NEUROSIS OF THE (ESOPHAGUS. 
1027 
Treatment.-If the pathological view advanced for the explanation of 
oesophageal stricture is correct, then it is the duty of the physician to en- 
deavor to ascertain where the seat of irritation is. If in the canal itself, and 
not dependent on a positive lesion of its walls (a fact which will be rendered 
probable by the spasm being excited only by local impressions, as swallow- 
ing liquids at a certain temperature, or solids of a peculiar kind, or on the 
passage of an oesophageal sound), then the treatment which consists in 
frequently passing bougies and stretching the walls of the tube, with the 
internal use of iron, assafoetida, and strychnia, and an active out-door life, 
will secure the best results. When, coexisting with spasm, there can be dis- 
covered uterine, gastric, or vesical disease, or any other lesion, irritations 
from which might be transmitted to the nerves of the par vagum, the cor- 
rection of such will be clearly indicated as preliminary to all other treatment. 
In all cases, arising from whatever cause, attention must be paid to the 
general health, for the improvement of which a judicious combination of 
tonics and antispasmodics should be administered. Among the latter, bro- 
mide of potassium will prove particularly beneficial, from its well-known 
property of diminishing cerebral sensibility. A treatment of this kind, sup- 
plemented by a change of air, scene, and companionship, can scarcely fail 
to work a cure in due time. 
Paralysis.-The oesophagus sometimes participates with the pharynx, 
tongue, lips, and other muscles of the mouth in a loss of power due to struc- 
tural degeneration in the medulla oblongata (bulbar paralysis), and which 
admits of no remedy. (Esophageal paralysis may also occur to some extent 
among the phenomena of diphtheria, syphilis, and lead-poisoning, and also 
in general paralysis, as witnessed in concussion of the brain. Other causes 
which are not central are capable of inducing loss of muscular power in the 
tube. Thus, its walls may be disabled by over-distention, by carcinomatous 
infiltration, or by the interruption of nerve-power in consequence of wounds 
or of pressure from tumors and inflammatory accumulations. 
Symptoms.-Among the most prominent of these is dysphagia, the degree 
of which will depend on the partial or general extent of the paralysis, and 
also on the extent to which the sensory endowments of the tube are impaired. 
The food is arrested after entering the oesophagus, remaining there until 
urged onward by successive installments of aliment and repeated draughts of 
liquids, until, at length, it reaches the stomach. The disease is not attended 
with pain, nor is the food returned with the same frequency as in coarcta- 
tions of the tube. 
Diagnosis.-Paralysis of the oesophagus can be distinguished from stricture 
by the fact that large masses of food are swallowed with greater ease than 
smaller ones, and solids with less difficulty than liquids ; neither is there any 
difficulty experienced in the introduction of the sound. 
Prognosis.-When dependent on syphilis, diphtheria, the poisonous effects 
of lead, or the presence of inflammatory effusions or hemorrhages capable of 
being removed by the absorbents and veins, there is a fair prospect of re- 
covery, though the progress will be slow. When the paralysis is due to 
central causes, recovery can be anticipated only to the extent to which such 
causes are removable. 
Treatment.-Paralysis dependent on the constitutional operation of syphi- 
litic, diphtheritic, or lead poison requires that these conditions shall be cor- 
rected by appropriate treatment: if the muscular power does not then return, 
strychnia should be administered until its peculiar constitutional effects are 
obtained. In the absence of motor power in the walls of the oesophagus, the 
food which collects in the tube may require to be pushed onward into the 
stomach by the probang; or, when the deglutition is very imperfect, it will 
be better to support the patient by introducing the nourishment through the 
oesophageal tube. 1028 
SURGICAL DISEASES OF THE MOUTH. 
(Esophagotomy. 
The operation of opening the oesophagus by an external incision was first 
suggested by Verduc, in 1643. In 1747, Guattani, a distinguished Italian 
surgeon, by experiments on animals and on the human cadaver, showed that 
there was no serious anatomical obstacle in the way of its execution, and in 
addition reported two instances in which the oesophagus bad been opened 
successfully on account of foreign bodies which had become impacted in the 
tube,-the one by Goursault, of Limousin, in 1738, and the other by Ro- 
land. In 1820, Berlinghieri, at Pisa, introduced an instrument into the 
oesophagus through the mouth, intended to cause the wall of the gullet to 
swell so that it could be certainly exposed on the side of the neck, between 
the superior and inferior thyroid arteries. Begin was the first to formulate 
definitely the rules for the performance of the operation, based on his own 
personal practice and observation. He modified the methods of Guattani 
and Boyer. The former exposed the oesophagus between the trachea and 
the sterno hyoid and thyroid muscles, and the latter between the sterno- 
hyoid and sterno-cleido-mastoid muscles. Begin opened the space between 
the trachea and sterno-hyoid and sterno-thyroid muscles on one side, and 
the sterno-cleido-mastoid muscle, carotid artery, internal jugular vein, pneu- 
mogastric and sympathetic nerves on the other. 
In 1844 cesophagotomy was performed by Watson, of New York. 
Circumstances requiring cesophagotomy.-The circumstances which require a 
resort to this operation are : 
1st. The presence of a foreign body impacted in the cervical portion of the 
oesophagus so firmly that all measures employed for its removal have failed. 
2d. The presence of a malignant or other growth in the lower part of the 
pharynx or the commencement of the oesophagus, which prevents the passage 
of the food. 
3d. The removal of a morbid growth, the form and position of which are 
favorable to an operation, through the neck, when the operation is not feasible 
through the mouth. 
Operation.-The patient should be placed on the back, the shoulders mod- 
erately elevated, and the head thrown back and turned towards the right 
side. An incision is now commenced on the left side of the neck, midway 
between the thyroid cartilage, half an inch below its upper border, and the 
sterno-mastoid muscle, and carried down parallel with the anterior border of 
the last-named muscle, terminating about one inch above the sterno-clavicu- 
lar articulation. The skin being divided, the superficial fascia and platysma 
myoides muscle are to be raised on a director and divided to the full extent 
of the first incision, taking care not to injure the anterior jugular vein, 
which usually is found along the inner edge of the sterno-mastoid muscle. 
The deep fascia, now exposed, is incised in like manner, when the sterno- 
hyoid and thyroid muscles will be seen lying along the inner side of the 
wound, the sterno-cleido-mastoid muscle and the sheath of the carotid vessels 
on the outer side, and, some distance below, the tendon of the digastric muscle. 
The sheath containing the carotid artery, internal jugular vein, and pneumo- 
gastric nerves must now be pushed in an outward direction, while the loose 
cellular tissue between the vessels and the trachea is to be broken up with 
the director or a finger, taking care not to injure the superior thyroid and in- 
ferior thyroid arteries. The oesophagus will now be exposed, lying between 
the trachea and the vertebra?, and at the middle of the neck, a little to the 
left side of the trachea. The recognition of the oesophagus may be deter- 
mined in three ways: first, the foreign body, when the operation is for the 
removal of such, can be felt through the walls of the tube ; secondly, by intro- 
ducing a sound or bougie through the mouth and pharynx into the gullet, 
and protruding the side of the latter on its point; thirdly, by observing the 
alternate distention and collapse of the tube in the acts of inspiration and 
expiration. OESOPHAGOTOMY. 
1029 
These respiratory movements of the oesophagus I noticed while assisting 
Dr. Packard, of this city, in a case of oesophagotomy. 
After the tube has been identified, its sides should be raised with the for- 
ceps and punctured, when the opening can be enlarged in a longitudinal 
direction to the required extent by either a blunt-pointed bistoury or scissors. 
When the object of the operation is to nourish the patient, the rubber oeso- 
phageal tube is to be introduced through the wound, and a portion of the 
latter closed above and below by sutures. When the operation is done for 
the extraction of a foreign body, it should be closed, and the subsequent 
management of the case, as regards both dressing and after-treatment, will 
be the same as that described for wounds of the cesophagus. 
The operation of pharyngotomy does not differ materially from that of 
oesophagotomy, except that the incision commences on a level with the great 
horn of the hyoid bone and terminates one inch below the cricoid cartilage. 
The ligation of the superior thyroid artery will probably be required, as it 
crosses the track of the incisions. 
Hesults.-In 1848, De Lavacherie presented to the Belgian Academy of 
Medicine an analysis of 83 cases of oesophagotomy, of which number 18 
were speedily fatal, 17 died from various subsequent complications at longer 
or shorter intervals, 12 died from hemorrhage, 26 were followed by serious 
ill results, though not proving fatal, and 10 were followed by abscesses, with 
escape of the foreign body in that way. 
Internal oesophagotomy was performed in two cases by M. Dolbeau on 
account of oesophageal stricture caused by sulphuric acid. The patients 
were both females, and both recovered. 
The table given on the following three pages embraces 36 cases of external 
oesophagotomy. 1030 
SURGICAL DISEASES OF THE MOUTH. 
No. 
Date. 
Sex and 
Age. 
Source of Information. 
Nature of Foreign 
Body. 
Point of Impaction. 
Treatment before 
Operation. 
Time of Opera- 
tion. 
Result. 
Cause of Death. 
Operator. 
1 
1738. 
M. 
Boston City Hospital Re- 
ports, p. 522. 
Portion of bone one 
inch long and six 
(Esophagus - where 
not stated; felt out- 
Attempts to push 
down. 
Cured. 
Goursault. 
Boston City Hospital Re- 
ports, p. 522. 
Amer. Jour. Med. Sci., 
lines broad. 
side. 
2 
3 
1831. 
M. 
Portion of bone. 
Below cricoid carti- 
Forceps and probang. 
12th day. 
Cured. 
Cured. 
Roland. 
Begin. 
vol. xiii p. 251. From 
Jour. Hebdom., April, 
lage. 
1833, No. 1:35. 
4 
1831. 
M. 
Amer. Jour. Med. Sci., 
Portion of bone. 
(Esophagus, lower 
Emetics, forceps, and 
8th day. 
Cured. 
Begin. 
vol. xiii. p. 251. From 
Jour. Helxlom., April, 
part ot neck. 
probang. 
1833, No. 135. 
5 
1833. 
Child. 
St. Barth. Hosp. Rep., vol. 
Fragment bone (spi- 
Lower part of phar- 
Emetics and various 
After 5 weeks, on 
Death in 56 
Pneumonia at time 
Arnott. 
iv. p. -z04. From Med.- 
Chir. Trans. 
nous process, dorsal 
vertebra, sheep). 
ynx. 
attempts to dis- 
lodge. 
right side, at 
Middlesex Hos- 
hours. 
of operation. 
6 
1842. 
M. 
Half-Yearly Abst. Med. 
Sci., vol. iii.p. 215. From 
Portion of bone. 
(Esophagus perfora- 
ted; lying on ca- 
pi tai. 
8th day. 
Cured. 
De Lavacherie. 
Jour, de Chirurg., Nov. 
1, 1845, p. 337. 
Half-Yearly Abst. Med. 
rotid. 
7 
1844. 
M. 
Portion of bone. 
Felt outside, over 
Bleeding, tartar emet- 
4th day; bone 
Death in 2 days. 
Collapse; pharynx 
Martini. 
Sci., vol. ii. p. 120. 
clavicle. 
ic into veins, bella- 
swallowed. 
gangrenous; stom- 
donna enemata,and 
ach inflamed; bone 
8 
1844. 
M.» 24. 
Boston Med. and Surg. 
Tuberculous stricture. 
Extended into larynx; 
sixty attempts to 
dislodge. 
lived two months and 
eight days after 
Death 1 week 
found in rectum. 
Watson. 
Jour., vol. xxx. p. 506. 
From N. Y. Jour, of 
gullet was opened, 
then tracheotomy 
done. 
after. 
Med. 
9 
1853. 
M. 
Boston City Hosp. Rep.. 
Small fish. 
Pharynx; tail seen in 
Attempts to draw 
Several days. 
Cured in 6 weeks. 
Antoniecz. 
p. 522. 
fauces. 
through mouth. 
10 
1853. 
M. 
Boston City Hosp. Rep., 
p. 
Fragment of beef- 
bone. 
(Esophagus, in neck. 
Attempts to extract. 
9th day. 
Death 2d day. 
Perforation front 
and behind; retro- 
Flaubert. 
pharyngeal ah- 
11 
1854. 
F. 
Boston City Hosp. Rep., p. 
One-franc piece. 
Upper part of oesoph- 
Used Graefe's sound 
10th day. 
Death 3d day. 
scesses reach stom- 
ach. 
Retro oesophageal ah- 
Demarquay. 
12 
1855. 
522. 
Boston City Hosp. Rep., p. 
522. 
Portion of bone. 
ague. 
(Esophagus; abscess 
formed. 
and forceps repeat- 
edly. 
Could not be reached 
bv forceps. 
16th day. 
Cured in 2 weeks. 
scess opening into 
pleura. 
Syme. 
13 
1856. 
M. 
Guy's Hosp. Rep., N. S., 
vol. iv. p. 217. 
Gold tooth-plate with 
false incisor. 
Junction of pharynx 
and oesophagus; no 
external projection. 
Forceps and emetics. 
4th day. 
Cured in 4 weeks ; 
permanent al- 
teration of voice. 
Cock. 
External (Esophagotomy. (ESO PH A G 0 TOMI 
1031 
No. 
Date. 
Sex and 
Age. 
Source of Information. 
Nature of Foreign 
Body. 
Point of Impaction. 
Treatment before 
Operation. 
Time of Opera- 
tion. 
Result. 
Cause of Death. 
Operator. 
14 
1861. 
F., 45. 
Brit. Med. Jour., Aug. 24. 
Flat piece of mutton- 
(Esophagus; noexter- 
Could not be touched 
6th day. 
Cured in 2 weeks. 
Syme. 
1861, p. 193. 
bone one inch 
nal projection. 
by forceps. 
Brit. Med. Jour., March 
square. 
16 
1862. 
M., 21. 
Copper coin. 
Opposite top of ster- 
Touched by bougie. 
3 months. 
Cured ; swallowed 
Syme. 
22,1862, p. 299. 
Boston City Hosp. Bep., p. 
num. 
in 1 week. 
16 
1862. 
M. 
Fragment of bone two 
Top of oesophagus. 
Attempts to extract. 
2d day. 
Cured in 4 weeks. 
Inzani. 
522. 
inches long. 
17 
1863. 
M. 
Boston City Hosp. Rep., p. 
5->2 
Bone. 
Cured. 
Sourier. 
18 
1864. 
M. 
Boston City Hosp. Rep., p. 
522. 
Biennial Retros. Med. and 
Peach-stone. 
Cured. 
Arnold. 
19 
1864. 
M., 37. 
Enlarged cervical 
Death 34th day. 
Gangrene of oesoph- 
Bruns. 
Surg. From Deutsche 
glands; gullet 
agus. 
Klinik, 1865, Nos. 4, 5, 
united to spine and 
8, 9. 
divided into two ca- 
nals by pendulous 
septum. 
20 
1866. 
M. 
Boston City Hosp. Rep., p. 
Codfisli-bone. 
Junction of pharynx 
Vomiting; finger and 
3d day (right 
Cured. 
Cheever. 
522. 
and oesophagus; no 
probang; rigors. 
side). 
projection. 
21 
1866. 
M. 
Boston City Hosp. Rep., p. 
Brass pin. 
Below topof sternum; 
Vomiting; long pro- 
3d day. 
Cured in 5 weeks 
Cheever. 
522. 
no projection. 
bang. 
22 
1867. 
M., 33. 
Guy's Hosp. Rep., 3d Se- 
Silver tooth-plate. 
Opposite left cricoid. 
Attempts to extract. 
Cured. 
Cock. 
ries, vol. xiii. p. 1. 
23 
1867. 
F., 47. 
St. Barth. Hosp. Rep., vol. 
Abscess at cricoid car- 
tilage following dila- 
tationof stricture; re- 
Death 18th day. 
Willett. 
iv. p. 204. 
duced to last ex- 
tremity before sub- 
mitting to operation. 
24 
1867. 
F., 49. 
Boston Med. and Surg. 
Common pin. 
Apparently opposite 
Attempts during four 
After 4 months 
Cured. 
Hitchcock. 
Jour., N. S., vol. i. p. 
left cricoid. 
months. 
no foreign body 
3 4 3. 
found. 
25 
1868. 
F. 
Boston City Hosp. Rep., p. 
Supposed to have been 
Junction of pharynx 
Various attempts. 
After 8 months 
Cured. 
Cheever. 
522. 
a pin. 
and oesophagus. 
no foreign body 
found. 
26 
1869. 
F. 
Boston City Hosp. Rep.,p. 
Supposed mutton- 
Opposite thyroid car- 
None. 
10th day, no for- 
Cu red; oesophageal 
McLean. 
522. 
bone 
tilage. 
eign body found. 
abscess opened. 
27 
1870. 
F. 
Boston Med. an<l Surg. 
A cent one inch in 
Junction of pharynx 
Repeated efforts to re- 
5th day. 
Cured. 
Atherton. 
Jour., N. S., vol. vi. p. 
81. 
Practitioner, by Anstie, 
diameter. 
and oesophagus. 
move. 
28 
M., 11. 
Drank potash - lye 
Swallowed cherry- 
seed, and inability to 
2d day. 
Cured in 26 days. 
Billroth. 
vol. vi. p. 186. From 
seven jears previ- 
swallow was imme- 
diate; seed lodged in 
Wiener Med. Wochen- 
ous ; two strictures 
second stricture. 
schri ft, No. 56,1870. 
Practitioner, by Anstie, 
formed. 
29 
M., 44. 
Cancerous stricture 
(Vocal cords para- 
Used bougies and im- 
Death next day. 
Billroth. 
vol. vi. p 186. From 
for over one year. 
lyzed.) 
proved. 
Wiener Med. Wochen- 
sehrilt, No. 56,1870. 
External (Esophagotomy.-(Continued.) 1032 
SURGICAL DISEASES OF THE MOUTH. 
No. 
Date. 
Sex and 
Age. 
Source of Information. 
Nature of Foreign 
Body. 
Point of Impaction. 
Treatment before 
Operation. 
Time of Opera- 
tion. 
Result 
Cause of Death. 
Operator. 
30 
1874. 
M., 30. 
Med. Rec., vol. xi. p. 282. 
Crescent-shaped (one 
and one-half inches 
Behind thyroid carti- 
lage. 
Attempts with forceps 
(voice impaired, but 
Cured in 22 days. 
McLean. 
31 
1874. 
M. 
Med. Rec., vol. xi. p. 282. 
by one-half inch) 
gold tooth-plate. 
Dislodged four false 
Cardiac portion of 
recovered). 
Attempts to remove. 
11 months 7 days. 
Cured. 
McLean. 
teeth with plate; 
remained eleven 
oesophagus. 
months and seven 
days, and formed 
stricture. 
32 
F. 
Med. Rec., vol. xi. p. 828. 
From Journ. de Med. et 
Fragment of bone. 
Attempts to push 
down. 
Cured, 
Cozin. 
33 
1878. 
F., 49. 
Chirurg., Nov. 1876 
Boston Med. and Surg. 
Flat fish-bone one and 
Opposite cricoid carti- 
Sponge and bristle 
Next day. 
Cured in 20 days. 
Gay. 
Jour., N. S., vol. c. p. 
356. 
three-fourths inches 
long by one-third 
inch wide. 
lage in posterior 
wall of pharynx. 
probang. 
34 
1878. 
F. 
Trans. Clin. Soc. of Lon- 
False teeth. 
Opposite middle of 
Probang. 
3 weeks. 
Cured. 
McKeown. 
don, vol. xi. p. 233. 
thyroid cartilage, 
and extending 
nearly to sternum. 
35 
1879. 
F., 30. 
Lancet, Feb. 1, 1879, p. 
Piece of vulcanite 
Behind glottis, but 
Attempts with for- 
13 days. 
Cured. 
Alexander. 
155. 
tooth-plate one-half 
inch long by one- 
disappeared by pa- 
tient's own efforts 
ceps. 
36 
1879. 
F., 30. 
quarter inch broad. 
Malignant growth of 
to remove; pain at 
middle of gullet. 
Died. 
Packard. 
tlie pharynx pre. 
venting the use of 
nourishment. 
Of the above 36 cases of cesophagotomy, 27 recovered and 9 died. The operation was performed 32 times for the removal of foreign 
bodies, which in most instances were lodged at or near the pharyngo-oesophageal junction, and which had resisted the ordinary 
means for their extraction. Of the remaining 4 operations, 1 was done for the relief of stricture produced by swallowing a caustic 
alkali, 2 were on account of carcinoma, and 1 was in consequence of obstruction occasioned by the pressure of enlarged lymphatic 
glands. In 2 cases in which the gullet was opened for foreign bodies none were found. 
External (Esophagotomy.-( Continued.) POISONS AND THEIR TREATMENT. 
1033 
Poisons taken into the Stomach, and their Treatment. 
In those emergencies which arise from accidentally or intentionally taking 
poisons into the stomach the surgeon is often called upon suddenly to render 
professional aid. 
These poisons may be briefly considered under the usual classification of 
mineral and vegetable. 
Mineral Poisons.-The principal poisonous substances of this class are 
arsenic, corrosive sublimate, nitrate of silver, corrosive acids, as sulphuric, 
nitric, and muriatic, salts of copper or lead, and phosphorus. The symp- 
toms which attend a poisonous dose of any of these articles are those of 
great gastric irritation, pain and distress, and, in the case of the mineral 
acids named, of violent irritation, swelling, and burning heat along the whole 
extent of the alimentary tract from the lips to the stomach. 
Treatment.-The treatment is both antidotal and evacuating. The first 
is based on the chemical reactions of the substances swallowed,-the effort, 
in other words, to ally them with some material for which they are known 
to have a strong affinity, and their union with which results in the formation 
of an inert or harmless compound. 
In the case of arsenic, the hydrated sesquioxide of iron, freely adminis- 
tered, converts the poison into an arsenate of iron, which is innocuous. Until 
this agent can be employed, milk, the white of eggs, ox* flour, which are 
almost always at hand, may be administered. Both in America and in Europe 
a very large proportion-three-fourths-of the cases of criminal poisoning 
are done with arsenic. 
If the poison is corrosive sublimate, the white of eggs, milk, and the 
protosulphuret of iron will constitute the proper remedies. This prepa- 
ration of mercury forms with albuminous compounds an albuminate of 
mercury. 
Nitrate of silver is rendered inert by the use of common table-salt, the 
latter converting the salt into an insoluble chloride of silver. The poisonous 
effects following the use of the salts of copper are best counteracted by the 
white of eggs or albumen, and by calcined magnesia, and those resulting from 
the preparations of lead by the administration of alkaline sulphates, as sul- 
phate of soda or magnesia, or by giving very dilute sulphuric acid, which 
changes the poison into the sulphate of lead. The precaution given by 
toxicologists in the treatment of poisoning from the carbonate of lead by 
the antidote named above is to use the dilute acid at short intervals, not 
continuously, as the evolution of carbonic acid which follows the use of the 
remedy might cause dangerous distention of the stomach. 
In the case of poisoning by the mineral acids, the exhibition of alkalies 
will be indicated ; and, with a view of soothing the mucous coat of that part 
of the alimentary tube above the stomach, and of shielding the stomach, 
sweet oil should be given. 
Phosphorus when taken in poisonous quantities, as sometimes happens 
wfith children, who in their ignorance swallow the ends of matches, should be 
dislodged immediately from the stomach by emetics or by the stomach-pump. 
The antidote which seems to answer best is the sulphate of copper, which, in 
addition to possessing the property of an emetic, forms with the phosphorus, 
according to Bamberger, an insoluble compound. 
Vegetable Poisons,-The vegetable poisons most frequently taken are 
opium, belladonna or atropia, strychnia, and oxalic acid. 
Symptoms.-The symptoms which characterize the poisonous action of 
narcotic principles derived from the vegetable kingdom are due to impres- 
sions made on the brain, on the spinal marrow, or on both, as manifested by 
vertigo, dimness of vision, stupor, stertorous breathing, convulsions, etc. 
The poisonous effects of opium are best counteracted by washing out the 1034 
SURGICAL DISEASES OF THE MOUTH. 
stomach with the stomach-pump, using at the same time fluid containing 
tannin or tannic acid. The patient must also be kept in motion or walking 
with the aid of an assistant on each side. 
Atropia-poisoning is to be met with the free use of tannin and charcoal, at 
the same time employing emetics and the stomach-pump. Digitalis, cottee, 
camphor, and other cardiac stimulants may also be demanded. 
Strychnine-poisoning is best counteracted by an emetic of sulphate of 
copper or zinc. Tannic acid should be administered, and when feasible the 
stomach-pump must be employed. In case of convulsions being present, the 
inhalation of chloroform, or the exhibition of chloral hydrate, will be indi- 
cated. In extreme cases artificial respiration must not be overlooked. 
Oxalic acid, which is a very deadly vegetable poison, finds its best antidote 
in lime or powdered chalk, with which substances there is formed -an in- 
soluble oxalate of lime. 
After the use of antidotes, and even before, in many cases, the employment 
of emetics in order to evacuate the stomach is exceedingly important. When 
these are administered immediately after the ingestion of the poison, the latter 
may often be dislodged from the viscus before any evil effects are experienced. 
The substances commonly in use for this purpose are powdered mustard, a 
large spoonful of which should be thrown into half a pint of lukewarm water 
and immediately drunk. Sulphate of zinc, from the promptness with which 
it induces emesis, is another valuable agent. Twenty grains dissolved in a 
wineglassful of water will produce the desired effect; or the same amount of 
ipecacuanha may be administered. All of these emetics should be assisted 
by irritating the fauces with a finger or a feather in order to hasten vomiting. 
In many cases the reflex sensibility of the stomach has been so destroyed 
by the absorption of the poison into the system that it becomes necessary to 
remove its contents by the use of the stomach-pump, an instrument adapted 
not only to cases of gastric torpor, but also to most cases of poisoning by 
substances taken into the stomach. 
The artificial introduction of fluids into the stomach, and the use of the stomach- 
pump.-In consequence of wounds of the pharynx and the oesophagus, or 
from the moods of the insane, it frequently becomes necessary to introduce 
nutritious fluids into the stomach by means of the oesophageal tube. In other 
instances, where poisons have been swallowed, either accidentally or design- 
edly, it is required that the stomach should be promptly emptied of its con- 
tents. For effecting the first object, that is, the introduction of nourishment, 
two methods can be employed, namely, by 
the syringe and by gravity. The tube 
(Fig. 1G83) for conveying the liquids may 
be passed into the oesophagus through cither 
the mouth or the nose. The latter is prefer- 
able, as the muscular resistance of the fau- 
cial muscles is thereby avoided. Sometimes, 
owing to deviation of the septum, or pecu- 
liar conformation of the nasal cavities, dif- 
ficulty will be experienced in introducing 
the tube. When such is found to bo the 
case on one side, the other nasal passage should be tried. When the special 
tube is not at hand, a long No. 17 gum catheter may be conveniently ex- 
temporized for the purpose. 
Operation by the syringe.-The patient being seated on a low stool or chair, 
with the head well thrown back, the surgeon introduces the elastic tube or 
soft catheter, previously well oiled, into the anterior meatus of one side of 
the nose, and, turning its point towards the floor of the nasal cavity, pushes 
it gently along the fossa until it reaches the pharynx, against the posterior 
wall of which it will sometimes become arrested. A little additional pressure 
will overcome the resistance, and the tube will continue to descend until it 
has passed into the oesophagus. If the instrument is used on account of a 
Fig. 1683. 
Nasal and oral oesophageal tube. POISONS AND THEIR TREATMENT. 
1035 
wound of the latter, it is necessary to carry it some distance beyond the seat 
of the lesion. If no complication of this nature exists, and the object is solely 
to sustain animal life, the tube need not be carried more than one or two 
inches below the pharynx. While held in this position, the nozzle of a gum 
bag charged with the liquid aliment, or that of a Davidson's syringe (previ- 
ously filled and afterwards supplied with the same material from a basin), 
is to be fitted into the tube, when the contents are to be gradually forced 
through the tube into the oesophagus. In the one case this is done by com- 
pressing the gum bag; in the other the bulb of the syringe is compressed 
with the fingers. The liquid must always be introduced slowly, in order not 
to distend the walls of the stomach suddenly ; in other words, the natural 
manner of taking food should be followed. 
Artificial alimentation by the gravity 
method consists in using a gum tube having 
at one end a large, funnel-shaped expan- 
sion for the reception of the liquid after the 
tube has been introduced into the oesophagus. 
The aliment is passed into the stomach by 
raising the funnel-shaped receptacle above 
the level of the pharynx. (Fig. 1684.) 
Tns/rzmentaZ evacuation of the stomach.- 
For removing the contents of the stomach 
in case of poison being taken into the viscus, 
it is necessary to employ the stomach-pump. 
The apparatus with the necessary appliances 
consists, first, of the pump with its two 
branches, one at right angles to the other, 
and each supplied with a valve, opened or 
closed at pleasure by a lever; second, two 
gum tubes, one (long) for the stomach and 
the other (short) for the discharge and the 
supply of liquids; third, a wooden screw in 
order to force the jaws apart; and, last, a 
wooden ring for the double purpose of keep- 
ing the maxilla) asunder and the protection 
of the stomach-tube against the teeth. (Fig. 
1685.) 
The apparatus is expensive. A substitute 
for it is an ordinary metallic or hard rubber 
enema syringe of large size, with stop-cock and a stomach-tube. 
Operation.-The patient sits on a low stool or chair, with the mouth kept 
open by the wooden or cork gag. The surgeon stands in front, and intro- 
duces, with the usual precautions, the long gum tube into the stomach; the 
syringe, charged with some bland or possibly neutralizing fluid, is fitted to 
the end of the tube, and its contents forced into the stomach. The next step 
is to withdraw the piston, in doing which the fluids of the stomach will be 
drawn into the barrel of the instrument. After closing the stop-cock and 
pushing home the piston, the contents of the syringe will be discharged into 
the basin, when, by repeating the process of opening the valve and withdraw- 
ing the piston, another installment of fluid can be removed. (Fig. 1686.) In 
this simple manner the stomach can be cleared of poisonous substances and 
its cavity washed out. When the stomach-tube is being withdrawn, the ex- 
ternal orifice should be closed with the end of the thumb until the instru- 
ment has been entirely removed, in order to prevent any portion of its 
contents from entering the larynx. 
There has been some difference of opinion as to the origin of the stomach- 
tube. Like many other inventions, its conception appears to have been the 
simultaneous product of two representative professional men, though living 
on opposite sides of the Atlantic. In 1797, Monro the younger, of Edin- 
Fig. 1684. 
Gravity apparatus for introducing aliment into 
the stomach. 1036 
SURGICAL DISEASES OF THE MOUTH. 
burgh, published a thesis in which the removal of poisonous substances from 
the stomach by instrumental means was suggested; but there is no evi- 
Fig. 1685. 
Stomach-pump complete. 
dence that these suggestions ever assumed any material shape or were ever 
carried into effect. About the same time, and without any knowledge of 
Fig. 1686. 
Evacuating the stomach by tube and syringe. 
the thesis of Monro, a similar idea had occurred to Dr. Physick, who not 
only had the tube constructed, but as early as 1800 was demonstrating 
its use in his public lectures to the students of the University of Penn- 
sylvania.* So far, therefore, as the practical consummation of the idea is 
concerned, Physick is entitled to at least equal credit with Alexander Monro 
for the discovery of what has been the means of saving the lives of many 
persons who must otherwise have perished. 
* American Medical Recorder. INDEX TO VOLUME II. 
A. 
Abscess, retropharyngeal,laryn- 
gotomy in, 1010. 
prognosis in, 1009. 
signs of, 1009. 
treatment, by aspiration, 
1009. 
sublingual, 909. 
Accidents during and after op- 
erations, 276. 
Acetabulum, fracture of, diag- 
nosis, 93. 
necrosed, in coxalgia, 186. 
perforation, in coxalgia, 167, 
170. 
Acupuncture, use of, 264. 
Adenitis in boils, 398. 
Adenoma of bladder, 548. 
of lip, 893. 
of soft palate, 983. 
Adhesions in phimosis, 428. 
rupture of, in anchylosis, 143. 
Adhesive plaster in luxation of 
clavicle, 47. 
Adipose tumor of scrotum, 520. 
of vulva, 722. 
Adynamia of bladder, 540. 
Albumen in urine, 618. 
Alimentation, artificial, 1034. 
Allis's inhaler, 285. 
Alopecia after erysipelas, 405. 
Alveolar abscess, 928. 
fistula after, 929. 
Alveolus, broken away, 936. 
Amputation, 293-375. 
absorbent dressings in, 314. 
after excision, 212. 
Alanson's plan of, 303. 
aneurismal varix atter, 323. 
antisepsis in, 315. 
assistants at, 312. 
author's plan of, 305. 
bulbous bone after, 321. 
bursa after, 323. 
Carden's plan of, 304. 
causes of mortality in, 332. 
Cheselden's plan of, 303. 
circumstances demanding, 
293. 
closing the stump after, 313. 
complications, primary, 317. 
secondary, 320. 
conical stump after, 321. 
contraction of tendons after, 
323. 
control of hemorrhage during, 
312. 
cradle for, 316. 
degeneration of stump after, 
323. 
Amputation, disposition of 
nerves in, 313. 
disposition of tendons in, 313. 
double, 324. 
drainage-tube in, 314. 
draining of blood before, 312. 
dressings after, 316. 
removal of, 316. 
for aneurism, 296. 
for deformities, 296. 
for frost-bite, 422. 
for injuries and diseases of 
bones, 294. 
of joints, 295. 
of soft parts, 293. 
for malformations, 296. 
for mortification, 30, 296. 
history of, 298. 
hemorrhage, recurrent, after, 
318. 
secondary, after, 320. 
hollow-cone section in, 303. 
in arthritis, 152. 
in compound dislocations, 29. 
of ankle, 120. 
of elbow, 76. 
of humerus, 66. 
of knee, 115. 
of wrist, 80. 
in dislocations of metatarsus, 
126. 
in elbow disease, 202. 
inflammatory results after, 
318. 
in joint wounds. 136. 
in primary reaction, 297. 
in rupture of popliteal ves- 
sels, 115. 
instruments for, 309. 
intermediary period in, 297. 
in white swelling, 190. 
in wrist disease, 203. 
isolation of vessels in, 313. 
Luke's plan of, 304. 
methods of, 300. 
comparison between, 307. 
mortality alter ordinary and 
after Lister dressing com- 
pared, 315. 
musculo-tegumentary, 304. 
advantages claimed for,308. 
author's plan in, 305. 
bi-, 304. 
history of, 307. 
objections to, 308. 
oval flaps in, 305. 
quadrangular flaps in, 306. 
semi-, 305. 
transfixion in, 304. 
1037 
Abdominal section in extra- 
uterine pregnancy, 834. 
Ablation in coxalgia, 186. 
of penis, 434. 
of tongue, 916. 
Abortion during renal colic, 
707. 
Abscess after amputations of 
forearm, 341. 
after gonorrhoea, 739. 
after periostitis of jaw, 949. 
after tonsillitis, 987. 
alveolo-dental, 928. 
artery incised for, 64. 
aspirated in coxalgia, 177. 
diagnosis from arthritis, 152. 
from Pott's disease, 875. 
from traumatic fever, 394. 
external to prostate, 498. 
extra-articular, in struma, 
160. 
in ankle disease, 191. 
in arthritis, 152. 
in back, 837. 
in coxalgia, 167. 
in dislocations, compound, 
28. 
of hip, 106. 
in old dislocations, 32. 
in pelvic cellulitis, 818. 
in Pott's disease, 881, 884. 
in sacro-iliac arthritis, 197. 
in white swelling, 186. 
intra-articular, in struma, 
160. 
lingual, 909. 
lumbar, 872. 
of antrum, 957. 
of jaw, 950. 
from teeth, 924. 
of kidney, 701. 
of labium, 717. 
of ovaries, 783. 
of palate, hard, 978. 
of palate, soft, 983. 
of parotid gland, 997. 
of prostate, 497. 
of tonsil, 992. 
of vulvo-vaginal gland, 718. 
perineal, from calculus, 647. 
perinephritic, 701. 
peri-urethral, 468. 
psoas, 872. 
retro-oesophageal, 1018. 
retropharyngeal, 1008. 
diagnosis from cervical, 
881. 1038 
INDEX TO VOLUME II. 
Amputation, necrosis after, 
320. 
neuralgia after, 322. 
excision of cicatrix for, 322. 
of nerve-plexus for, 322. 
of nerve-trunks for, 322. 
operation for, 309. 
osteomyelitis after, 320. 
period, intermediary, in, 297. 
inflammatory fever in, 297. 
period, primary, in, 296. 
period, secondary, in, 297. 
convalescence after, 298. 
in compound luxations, 30. 
plan preferred by Langen- 
beck, 304. 
pneumatic occlusion in, 316. 
position of patient during, 
312. 
protrusion of bone after, 319. 
Kavaton's plan of, 306. 
re-amputation, 326. 
for conical stump, 321. 
proper point for, 326. 
proper time for, 326. 
redundant flaps in, 314. 
retractor, use of, 301. 
secondary period in, 297. 
simultaneous, 324. 
abdominal tourniquet in, 
324. 
cases of, 324. 
conditions indicating, 324. 
Esmarch's bandage in, 324. 
spasm of stump after, 318. 
spicula in, 313. 
statistics of, 328. 
comparative mortality in 
hospitals, 331. 
of all causes, periods, and 
kinds, 329. 
of cause and period, 329. 
of causes of death, 332. 
of mortality, 330. 
stump depressed after, 315. 
subastragaloid, 358. 
sutures in, 314. 
synchronous, 324. 
Teale's plan of, 306. 
objections to, 308. 
tegumentary, 300. 
advantages claimed for, 
308. 
circular flaps in, 300. 
modifications of, 302. 
objections to, 307. 
oval flaps in, 303. 
single flap in, 304. 
triple incisions in, 303. 
use of saw in, 302. 
Vermale's plan, 304. 
Wharton's plan, 306. 
with reference to artificial 
limbs, 328. 
Amputations, special, 333-375. 
above shoulder, 350. 
results of, 351. 
at ankle joint, 358. 
compared with excision, 
244. 
Pirogoff's, 360. 
author's modification of, 
361. 
statistics of, 361. 
tenotomy in, 360. 
Syme's, 358. 
statistics of, 360. 
at elbow-joint, 342. 
Amputations, special: 
at elbow-joint, olecranon in, 
343. 
statistics of, 342. 
at hip-joint, 372. 
abdominal tourniquet in, 
372. 
by musculo-cutaneous flaps, 
373. 
by oval tegumentary flaps, 
373. 
advantages of, 373. 
causes demanding, 232, 
372. 
causes of mortality in, 372. 
compared with excision, 
231. 
compression of vessels per 
rectum in, 372. 
drainage-tube in, 373. 
Esmarch's bandage in, 372. 
history of, 374. 
methods of, 372. 
results of, 375. 
at knee-joint, 365. 
arterio-venous aneurism 
avoided in, 367. 
by lateral flaps, 367. 
by long anterior flap, 367. 
by oval flaps, 365. 
object of incision for, 366. 
by triple flaps, 367. 
compared with excision, 
237. 
disposition of patella in, 
366. 
history of, 365. 
results of, 367. 
at shoulder-joint, 346. 
compared with excision, 
216. 
followed by excision of 
scapula, 251. 
history of, 350. 
in secondary hemorrhage, 
65. 
method, Dupuytren's, 347. 
Larrey's, 346. 
Lisfranc's, 348. 
Spence's, 349. 
mortality in, 350. 
at wrist, 338. 
compared with excisions, 
223. 
statistics of, 339. 
styloid process in, 340. 
intra-uterine, 326. 
metacarpo-phalangeal, 335. 
inetatarso-phalangeal, 352. 
of arm, 344. 
author's method of, 344. 
mortality after, 345. 
Teale's method of, 345. 
tourniquet in, 344. 
of fingers, 333. 
of foot, 353. 
author's, or scapho-cunei- 
form, 356. 
Chopart's, or medio-tarsal, 
357. 
errors in. 357. 
objection to, 357. 
tenotomy after, 358. 
comparative merits of, 361. 
Hancock's, or subastraga- 
loid, 358. 
Hey's, or tarso-metatarsal, 
356. 
Amputations, special: 
of foot, Lisfranc's, or tarso- 
metatarsal, 355. 
position of tourniquet in, 
355. 
rules for, 354. 
surgical anatomy in, 353. 
various incisions for, 354. 
of forearm, 341. 
at lower third, 341. 
abscess in, 341. 
at middle and upper third, 
341. 
mortality after, 342. 
of hand,338. 
of leg, 362. 
at lower third, 362. 
point of election in, 362. 
at upper third, 363. 
after-treatment of, 364. 
tenotomy after, 364. 
mortality after, 365. 
never above tubercle of 
tibia, 365. 
spine of tibia rounded in, 
364. 
Teale's method of, 363. 
of little finger, 337. 
of metacarpal bones of the 
four fingers, 337. 
of metacarpo-phalangeal 
bones, 336. 
of metatarsus, 353. 
of penis, 432. 
of phalanges of foot, 352. 
of hand, 333. 
rules regulating, 333,338. 
statistics of, 338. 
of thigh, 368. 
at trochanteric part, 371. 
condyloid, 368. 
by Carden's method, 368. 
by Gritti's method, 369. 
by long posterior flaps, 
368. 
in shaft, by author's method, 
369. 
by Teale's method, 370. 
by Vermale's or lateral 
flaps, 370. 
mortality for shot wounds 
of, 371. 
results, 371. 
supra condyloid or Stokes's, 
369. 
of thumb, 336. 
of thumb and metacarpal 
bone, 336. 
of toes, 352. 
in dislocations of, 126. 
of tongue, 916. 
in hypertrophy of, 906. 
of uterus, inverted, 765. 
Anaesthesia, respiratory, 290. 
Anaesthetics, 280. 
advantages of, 281. 
alarming symptoms from, 278. 
avoided in cerebral trouble, 
283. 
comparison between, 290. 
competent assistant for, 282. 
foreign bodies in mouth under, 
282. 
general, 283. 
bichloride of methylene, 
289. 
chloroform, 286. 
ether, 283. INDEX TO VOLUME II. 
1039 
Anaesthetics, general: ethidene, 
289. 
nitrous oxide, 289. 
rapid respiration as, 290. 
history of, 280. 
in anchylosis, diagnosis of, 
142. 
treatment of, 143. 
in coxalgia, 184. 
in dislocations, 24, 31, 43, 72, 
85, 94, 110, 115. 
in extracting teeth, 933. 
influence upon mortality, 281. 
in lithotrity, 654. 
in malpositions, 162. 
in pseudarthritis, 205. 
local: carbolic acid, 292. 
ether, 292. 
frigoritic mixture, 291. 
rhigolene, 292. 
objection to mixtures of, 282. 
position in, 282. 
precautions in using. 282. 
supposed contra-indications 
for, 283; 
while sounding the bladder, 
643. 
Anal fissure, with neuralgia of 
urethra, 476. 
Anasarca of scrotum, 518. 
Anatomical boundaries of sub- 
maxillary gland, 995. 
components of joints. 130. 
knowledge in dislocations, 59. 
relations of jaws, 946. 
structure of anthrax, 400. 
Anatomy in dislocations, 17,24, 
111. 
in lateral lithotomy, 666. 
in lithotomy upon child, 674. 
in venesection, 265. 
morbid, after traumatic fever, 
389. 
in early death from, 391. 
of encephaloid of testis, 
590. 
of orchitis, chronic, 586. 
strumous, 588. 
syphilitic, 586. 
of bend of arm, 265. 
of foot, 353. 
of hydrorachis, 851. 
of parotid region, 1000. 
of spinal region, 837. 
of spine, 848, 859. 
of wrist, 81. 
Anchylosis, 140. 
after burns, 416. 
diagnosis, anaesthetic in, 142. 
false or incomplete, 141. 
after fractures, 141. 
after spine injuries, 857. 
disability after, 142. 
from lack of synovia, 141. 
pathology of, 141. 
treatment of, 142. 
anaesthetics in, 143. 
apparatus in, 144. 
fracture during, 143. 
tenotomy in, 142. 
in arthritis, occipito-atloid, 
196. 
strumous, 161. 
in coxalgia, 170, 174. 
fibrous, 183. 
osseous, 183. 
in strumous joints, 150, 187. 
in wounds of joints, 134, 136. 
Anchylosis, of elbow, pseudar- 
throsis in, 216. 
of knee-joint, 145. 
statistics of operations for, 
145. 
treatment, by fracture, 146. 
by resection, 146. 
by subcutaneous osteot- 
omy, 146. 
of lower jaw, 946. 
anmsthetics in, 283. 
pathological, 947. 
reflex, 947. 
treatment of, 947. 
prevention of, in excision of 
elbow, 218. 
repair by, in Pott's disease, 
877. 
true or complete, 140. 
pathology of, 140. 
treatment by operations, 
144, 145. 
when desirable, 142. 
Aneurism, amputation in, 296. 
arterio-venous, 367. 
diagnosis from Pott's disease, 
875. 
in old dislocations, 32. 
Aneurismal tumor of palate, 
979. 
Angeiomata of back, 839. 
of gums, 922. 
of tongue, 911. 
Angioleucitis, diagnosis from 
erysipelas, 408. 
Angular curvature of spine, 869. 
Animal ligature in amputations, 
313. 
in Caesarean section, 821. 
in cancer of tongue, 914. 
in ovariotomy, 807. 
Ankle, amputations at, 358. 
disease of, 190. 
dislocations of, 116. 
excision of, 241. 
reflex in nerve-lesions, 848. 
Anodynes in exhaustion, 277. 
Anteflexion of uterus, 759. 
Anteversion of uterus, 758. 
Anthrax, 399. 
anatomical structure of, 400. 
arrest of hemorrhage in, 401. 
carbolic acid as preventive of, 
953. 
causes of, 399. 
characteristics of, 399. 
cribriform apex in, 399. 
of lip, 892. 
prognosis in, 400. 
treatment of, 400. 
typhoid state in, 400. 
Antiseptic dressing in amputa- 
tions, 315. 
compared with ordinary, 315. 
in compound dislocations, 28, 
29, 77, 120. 
in excisions, 212. 
in nephrotomy, 713. 
in ovariotomy, 806. 
in wounds of joints, 135. 
An trace]e, 958. 
Antrum, abscess of, 957. 
loss of eye in, 958. 
treatment by perforation, 
958. 
carcinoma in, 961. 
dropsy of, 958. 
character of fluid in, 959. 
Antrum, dropsy of, pathology 
of, 958. 
treatment by perforation, 
959. 
fistula in, 959. 
inflammation of, 957. 
invaded by cysts, 939. 
tumors of, 960. 
protruding into nose, 960. 
Apparatus for anchylosis, 144. 
for ankle disease, 193. 
for coxalgia, 176. 
for lithotrity, 659. 
for spine disease, 865, 878. 
for white swelling, 188. 
Arachnitis in burns, 415. 
Arching in coxalgia, 164. 
in ischiatio dislocations, 94. 
Arm, amputation of, 344. 
avulsion of, 351. 
usefulness after excision of 
clavicle, 246. 
of shoulder, 214. 
Arsenical poisoning, 1033. 
Artery, axillary, incised for ab- 
scess, 64. 
ruptured in old dislocations, 
64. 
cases of, 64. 
symptoms of, 64. 
internal maxillary avoided in 
excision, 969. 
ligation of carotid, common, 
972. 
of carotid, external, 1001. 
of facial, 996. 
purulent absorption by, 386. 
Arthritic inflammation, disloca- 
tions in, 19. 
Arthritis, 150. 
changes of articulations in, 
149. 
causes, constitutional, 150. 
septic, 151. 
traumatic, 150. 
crepitation in, 152. 
destructive, in compound dis- 
locations, 28. 
diagnosis from extra-artic- 
ular abscess, 152. 
from pseudarthritis, 204. 
dry, or osteo-, 154. 
of hip, 155. 
of knee, 156. 
of shoulder, 156. 
of teinporo-maxillary joint, 
156. 
pathological changes in, 
157. 
symptoms of, 155. 
treatment of, 158. 
from constitutional causes, 
154-205. 
pathological changes of syno- 
vial membrane in, 152. 
symptoms of, 153. 
treatment of, 154. 
preternatural mobility in, 
152. 
resolution in, 151. 
rheumatoid. 154. 
simple, acute, and chronic, 
150. 
sinuses in, 152. 
spontaneous, in aged, 151. 
in tubercular families, 151. 
strumous or constitutional, 
158-205. 1040 
INDEX TO VOLUME II. 
Arthritis, strumous, acute, 158. 
character of pain in, 159. 
epiphyses involved in, 
158. 
prognosis, age in, 160. 
exciting cause in, 160. 
intensity in, 160. 
period of attack in, 
160. 
social condition in, 160. 
stages in, 159. 
symptoms of, 159. 
treatment by excision, 
162. 
by immobilization,! 61. 
treatment of malposi- 
tions in, 162. 
amputation in, 295. 
chronic, 162. 
treatment of, 162. 
of ankle-joint, 190. 
abscess in, 190. 
caries in, 192. 
causes of, 190. 
diagnosis from fibrous in- 
flammation, 191. 
from caries of tarsus, 191. 
epiphysitis in, 191. 
extension of foot in, 190. 
insidiousness of, 190. 
osteitis in, 191. 
passive motion in, 193. 
preternatural mobility 
F in, 190. 
prognosis in, 191. 
sinuses in, 191. 
structures involved in, 
190. 
treatment of, 191. 
of carpal joints, 202. 
of calcaneo-astragaloid 
and astragalo-scaphoid 
joints, 193. 
overlooked, 193. 
treatment of, 194. 
of elbow-joint, 200. 
amputation in, 202. 
exfoliation of epiphyses 
in, 201. 
origin of, 201. 
treatment by rest, 201. 
of hip-joint, 162. See 
Coxalgia. 
of knee-joint, 186. 
amputation in, 190. 
asymmetry in, 186. 
causes of, 186. 
excision in, 190. 
flexion in, 186. 
frequency of, 186. 
prognosis in, 187. 
spontaneous cure in, 189. 
tenderness in, 186. 
treatment by rest, 187. 
expectant, 189. 
of metatarso-phalangeal 
joints, 194. 
treatment by fixation, 
195. 
of occipito-atloid and atlo- 
axoid articulations, 195. 
anchylosis in, 196. 
causes of, 195. 
deformity in, 195. 
diagnosis from rheuma- 
tism, 196. 
from syphilitic necro- 
sis, 196. 
Arthritis, strumous, of occipito- 
atloid and atlo-axoid 
articulations, dyspha- 
gia in, 196. 
forward displacement in, 
195. 
necrosis in, 196. 
paralysis in, 196. 
pharvngeal abscess in, 
196. 
prognosis in, 196. 
sudden death in, 195. 
treatment by rest, 196. 
of saero-iliac articulation, 
196. 
causes of, 196. 
diagnosis from caries 
and necrosis of 
ilium, 198. 
from coxalgia, 197. 
from sciatica, 198. 
from spine disease, 
198. 
early swelling in, 197. 
elongation of limb in, 
197. 
pathology of, 196. 
prognosis in, 198. 
treatment by rest, 198. 
of shoulder-joint, 199. 
diagnosis from bursitis, 
200. 
from rheumatoid ar- 
thritis, 200. 
excision in, 200. 
frequency of, 199. 
subluxation in, 56. 
treatment by rest, 200. 
of sterno-clavicular and 
acromio-clavicular ar- 
ticulations, 198. 
excision in, 199. 
spontaneous luxation in, 
199. 
treatment by rest, 199. 
of tarso-metatarsal joints, 
194. 
treatment of, 194. 
of wrist-joint, 202. 
amputation in, 203. 
excision in, 203. 
treatment by immobili- 
zation, 203. 
suppuration in, 152. 
symptoms of, 151. 
theories concerning, 150. 
tissue-changes in, 152. 
Articular disease, 127-205. 
Articulation, after ablation of 
tongue, 919. 
new, after old luxations, 21. 
Articulations, absorption of, 18. 
changes of, after luxations, 
21. 
disability of, after luxations, 
22. 
inflammation of, 150. 
Artificial limbs, 327, 340, 365, 
371. 
amputation with reference 
to, 328. 
when allowed to wear, 327. 
Ascarides, incontinence of urine 
from, 545. 
Ascites, diagnosis from hydro- 
nephrosis, 704. 
ovarian dropsy, 796. 
renal cancer, 712. 
Asphyxia by nitrous oxide, 290. 
death from, under chloroform, 
288. 
under anaesthetics, 286. 
Aspiration in arthritis, 162, 
188, 202. 
of retained menses, 735. 
of spinal abscess, 883. 
Astragalo - calcaneo - scaphoid 
dislocation, 123. 
Astragalus, ablation of, 29,123. 
dislocations of, 121. 
excision of, 255. 
Asymmetry, causing spinal cur- 
vature, 862. 
in dislocations, 20. 
in white swelling, 186. 
Atony of bladder, 540. 
Atresia vaginae, 733. 
Atrophy after dislocations, 21, 
32. 
after spine injuries, 857. 
in osteo-arthritis, 156. 
of ovaries, 783. 
of testis, 597. 
of tongue, 906. 
of tonsil, 991. 
Atropia-poisoning, 1034. 
Avulsion of arm, 351. 
of arm, scapula, and clavicle, 
351. . 
Axillary artery, ligation of, 65. 
veins, rupture of, 65. 
B. 
Back, abscess in, 837. 
adipose tumor of, 838. 
angeiomata, or naevi, of, 839. 
blood tumors of, 837. 
bursal tumor of, 840. 
cancer of, 839. 
congenital tumors of, 840. 
cystic, 840. 
dermoid, 840. 
fatty, 840. 
foetal, 840. 
contusions of, 850. 
epithelioma of, 839. 
eruptions upon, 837. 
fibroma of, 839. 
furuncles upon, 837. 
inflammatory peculiarities of 
tissues of, 837. 
lipoma of, 838. 
sarcoma of, 839. 
sebaceous tumor of, 839. 
wounds of, 837. 
Balanitis, gonorrhoeal, 462, 
467. 
treatment of, 467. 
simple, 425. 
Bandage, Barton's, 37. 
Desault's, 47. 
posterior figure-of eight, 47, 
48. 
spica of shoulder, 249. 
spica of thumb, 86. 
Velpeau's, 47, 51, 62, 246. 
Bands for extension, 96. 
Battey's operation, 785. 
Bed-sores in spine injuries, 
856. 
in vertebral luxations, 45. 
Belladonna-poisoning, 1034. 
Bichloride of methylene, 289. 
Bile in urine, 623. INDEX TO VOLUME II. 
1041 
Bilharzia hmmatobia in bladder, 
538. 
Binders' board in luxations, 86. 
Bites, non-amputation in, 296. 
Bladder, abscess of, 532. 
absence of, 609. 
adenoma, papillary, of, 548. 
adynamia of, 540. 
aspiration of, 444. 
atony of, 540. 
atrophy of, 534. 
Bilharzia haematobia in, 538. 
capacity of, 508. 
carcinoma of, 548. 
changed in hypertrophied 
prostate, 503. 
coagula in, 540. 
congenital defects of, 609. 
contracted, 533. 
difficulty to enter, in lateral 
lithotomy, 671. 
in median lithotomy, 685. 
distended, in hypertrophy of 
prostate, 502. 
distention of, dribbling from, 
507. 
education of, in neurosis, 536. 
exploration of, after lithot- 
omy, 673. 
exstrophy of, 611. 
congenital deficiency in, 
450, 612. 
hernia with, 612. 
treatment of, 613. 
urinal for, 613. 
fasciculated, simulating cal- 
culus, 644. 
fibroma of, 546. 
fistula of, 681. 
gangrene of, 533. 
hernia of, 610. 
hypertrophied and sacculated, 
after stricture, 481. 
hypertrophy of, 533. 
inflammation of, 526. 
results of, 532. 
injecting of, in lithotomy, 
668. 
inversion of, 611. 
irritable, in gonorrhoea, 475. 
in Pott's disease, 873. 
in women, 828. 
neurosis of, 534. 
papilloma of, 547. 
paralysis of, 540. 
complicating lithotrity, 
660. 
cystitis in, 528. 
dribbling of urine in, 542. 
from overdistention of, 541. 
from centric causes, 541. 
in spine injuries, 854. 
lithotrity in, 653. 
residual urine in, 543. 
self-catheterization in, 543. 
treatment of, 542. 
urinary changes in, 542. 
paresis of neck of, 542. 
perforation of, in lithotrity, 
661. 
polypus of, 547. 
sarcoma of, 549. 
sloughing in cystitis, 527. 
stammering of, 511. 
stone in, 629. 
supernumerary, 610. 
tapping of, 512. 
tubercle of, 550. 
VOL. II.-66 
Bladder, tumors of, 546. 
treatment of, 549. 
ulceration of, 532. 
varix of, 537. 
washing, in lithotomy, 673. 
Blebs in erysipelas, 404. 
treatment of, in burns, 418. 
Blisters in neglected sprains, 
133. 
Blood concretions in kidney, 
640. 
effects of pus in, 387. 
in urine, 619. 
poisoning of, after fracture of 
penis, 436. 
Bodies movable in joints, 127. 
Boils, 397, 837. 
blood, 398. 
Bone, bulbous enlargement of, 
321. 
changes of, in arthritis, 149. 
in rheumatoid arthritis, 
157. 
in stump, 317. 
dislocation of cuboid, 125. 
of pisiform, 82. 
of scaphoid, 125. 
of semilunar, 81. 
exfoliation of, in white swell- 
ing, 189. 
exposed, in degenerated carti- 
lages, 149. 
in struma, 158. 
fragments of, removed from 
compound dislocations, 29. 
necrosed, in struma, 162. 
reproduced from periosteum, 
208. 
Bones, dislocation of carpal, 82. 
of cuneiform, 125. 
excision of metacarpal, 225. 
of metatarsal, 260. 
of phalangeal, 225. 
long, manner of growth of, 
209. 
medullary canal opened in, 
212. 
strumous inflammation of, 
158. 
Bougie, filiform, 486. 
oesophageal, 1022. 
soft, 483. 
steel, 483. 
Boutonniere, 494. 
Bowels, condition of, in spine 
injuries, 855. 
Brain, concussion of, retained 
urine in, 510. 
effects of chloroform on, 287. 
Bran dressing in compound dis- 
locations, 30. 
Broad ligament, cysts of, 812. 
Bronchitis, anaesthetics in, 283. 
Bubo after gonorrhoea, 469, 
739. 
Bulb of urethra, arteries of, 
wounded in lithotomy, 676. 
wound of, in median lithot- 
omy, 685. 
Burns, 412. 
amputation for deformity 
after, 420. 
anchylosis after, 416. 
classification of, 413. 
death from arachnitis in, 415. 
from gastro-enteritis in, 
415. 
from peritonitis in, 415. 
Burns, death from pleuro-pneu- 
monia in, 415. 
from tetanus in, 415. 
deformity after, 416. 
duodenal ulcer in, 415. 
exhaustion in, 415. 
frequency of dressing, 418. 
inflammatory fever in, 414. 
prognosis in, 415. 
removal of clothing and 
crusts in, 418. 
shock in, 414. 
skin-grafting in, 419. 
statistics of, 416. 
sun-, 423. 
treatment of, 417. 
of blebs after, 418. 
of caloric ulcer after, 419. 
of cicatricial contractions 
after, 419. 
Bursa after amputation, 323. 
Bursal tumors of back, 840. 
Bursitis, diagnosis from stru- 
mous arthritis of shoulder, 
200. 
psoas and iliac, diagnosis from 
coxalgia, 173. 
Cadaver, dislocations upon, 19. 
Caesarean section, 820. 
Calcareous deposits in testis, 
594. 
in urine, 629. 
Calcification of penis, 437. 
Calculus, in duct of Steno, 998. 
in submaxillary gland, 996. 
in tonsil, 985. 
salivary, 920. 
submaxillary, ligation of fa- 
cial artery in removal of, 
996. 
urinary, 629-707. 
age in, 629. 
alternating, 634. 
ammoniaco - magnesian, 
639. 
amorphous, 635. 
carbonate of lime, 639. 
causes exciting, 632. 
causes, probable predispos- 
ing, 631. 
changes in urine from, 642. 
chemical composition of, 
635. 
color of, 634. 
compound, 634. 
concentric, 636. 
consistence of, 633. 
construction of, 632. 
cystic oxide, 638. 
cystitis in, 528. 
diagnosis, source of fallacy 
in, 644. 
from prostatitis, 495. 
difficulties in detecting,644., 
from anteversion of blad- 
der, 645. 
from concealment of, 645. 
from depth of post-pros- 
tate pouch, 644. 
from escape into ureter, 
646. 
from hemorrhage, 646. 
from indifference to sen- 
sations, 645. 
c. 1042 
INDEX TO VOLUME II. 
Calculus, urinary, difficulties 
in detecting from pas- 
sive behavior of, 646. 
from sacculated bladder, 
644. 
from sacculated prostate, 
646. 
from suspension by 
lymph, 645. 
from vesical folds, 645. 
from vesical malforma- 
tions, 645. 
exploration for, in females, 
646. 
form of, 633. 
formation, theories of, 631. 
frequency, geographical re- 
lations to, 630. 
hemp-seed, 637. 
hereditary tendency to, 631. 
in bladder, 629. 
in females, 693. 
cystitis from, 827. 
frequency of, 693. 
rules for dealing with, 
696. 
in hypertrophied prostate, 
503. 
in kidney, 705. 
in scrotum, 520. 
in urethra, 453. 
measuring of, 646. 
micturition in, 640. 
mulberry, 637. 
nephritis after, 698. 
neuralgia of testis in, 596. 
nucleus of. 635. 
number of, 632. 
order of, 634. 
origin of, 629. 
oxalate of lime, 637. 
pain in, 641. 
parturition prevented by, 
648. 
pathological changes after, 
647. 
perineal abscess from, 647. 
phosphate of lime, 638. 
phosphates, mixed or fusi- 
ble, 639. 
triple, 639. 
physical signs of, 642. 
position of large, 656. 
priapism in, 642. 
prostatic, 505. 
race in, 631. 
rational signs of, 640. 
renal, 705. 
colic in, 707. 
composition of, 705. 
effects upon kidney, 706. 
frequency, as to age, 706. 
number of, 705. 
ova of distoma haemato- 
bium as nucleus of, 
705. 
pyelitis from, 699. 
rules for dealing with, 
693. 
sacculated, 644. 
sex in, 631. 
simple, 634. 
size and weight of, 632. 
smooth, 636. 
sounding for, 642. 
anaesthetics in, 643. 
condition of bladder in, 
643. 
Calculus, urinary, sounding for, 
note heard in, 643. 
sources of fallacy in, 
644. 
spontaneous expulsion of, 
650. 
rupture of, 648. 
symptoms of, 640. 
constitutional, 647. 
tenesmus in, 642. 
treatment by extraction, 
650. 
by local solvents, 649. 
urate of ammonia, 637. 
ureter packed with, 684. 
uric acid, 636. 
oxide, 637. 
varieties of, 636. 
vesical, 629. 
vesico-vaginal fistula from, 
742. 
xanthic oxide, 637. 
Callus in coxalgia, 170. 
in dislocations, 22. 
in excisions, 208. 
Cancer. See Carcinoma. 
soot, or chimney-sweep's, 525. 
Cantharides, retained urine 
from, 511. 
Carbolic acid as local anaes- 
thetic, 292. 
Carbuncle, 399. See Anthrax. 
Carcinoma of back, 839. 
of bladder, 548. 
of gullet, 1025. 
of jaw, lower, 957. 
upper, 961. 
of kidney, 710. 
of labium, 721. 
of lip, 894. 
of oesophagus, 1019, 1025. 
of ovary, 814. 
of parotid gland, 998. 
of penis, 432. 
of prostate, 506. 
of soft palate, 984. 
of spermatic cord, 558. 
of submaxillary gland, 995. 
of testis, 590. 
of tongue, 912. 
of uterus, 777. 
of vagina, 737. 
renal, 710. 
diagnosis from enlarged 
spleen, 712. 
from liver disease, 712. 
haematuria in, 711. 
urine in, 712. 
vesico-vaginal fistula from, 
742. 
Caries, amputation in, 295. 
in ankle disease, 192. 
in coxalgia, 166. 
in elbow disease, 202. 
in shoulder disease, 200. 
in spinal curvature, 869. 
in white swelling, 190. 
in wrist and carpal disease, 
203. 
of teeth, 927. 
superficial, of spine, diagnosis 
from Pott's disease, 876. 
Carotid, ligation of common, 
972. 
of external, 1001. 
Carpus, dislocation of, 78. 
congenital, 80. 
strumous disease of, 202. 
Cartilage, absorption of, in cur- 
vature of spine, 863. 
changes of, in rheumatoid ar- 
thritis, 157. 
degeneration of, in joints, 147. 
bone exposed in, 149. 
fibrous, 149. 
from arthritis, 149. 
granular, 158. 
pathology of, 148. 
origin of ankle disease in, 
190. 
Cartilages of joints, function of, 
147. 
of ribs, dislocation of, 39. 
excision of, 227 
semilunar, displacement of, 
114. 
Castration, 598. 
causes of death after, 600. 
for neuralgia of testis, 597. 
inguinal canal opened in, 600. 
operation for, 599. 
Casts in urine, 620. 
Catheter, author's blood, 508. 
cleanliness of, 552. 
incrustations upon, 442. 
in diagnosis of retention of 
urine, 507. 
in epispadias, 453. 
in gonorrhoea, 468. 
in haematuria, 540. 
in hypertrophy of prostate, 
504. 
in hypospadias, 452. 
in stricture of urethra, 487, 
491, 493. 
in urethroplasty, 449. 
in vesical fistula, 537. 
introduction of, in female, 
555. 
complications in, 556. 
in male, 552. 
errors in, 553. 
filiform guide in, 442. 
kinds of, 551. 
metallic, in wounds of penis, 
439, 441. 
retention of, 554. 
in wounds of urethra, 441. 
self-retaining, in vesieo-vagi- 
nal fistula, 747. 
soft, in cystitis, acute, 528. 
chronic, 529. 
in paralysis of bladder, 543. 
in urethral fistulae, 448. 
spiral, 510. 
Catheterism, 550. 
forced, 512. 
in cancer of prostate, 506. 
in chronic cystitis, 529. 
in dislocations of pelvis, 88. 
in hypertrophied prostate, 
504. 
in lacerated perineum, 732. 
in laceration of urethra, 441. 
in prostatitis, 496. 
in retention of urine, 512. 
in spine injuries, 859. 
in wound of spinal cord, 845. 
self-, 543. 
syncope during, 507, 555. 
Cautery in pseudarthritis, 205. 
Cells, nutrition of cartilages by, 
148. 
Cellulitis, diffuse, 405. 
pelvic, 817. 
abscess in, 818. INDEX TO VOLUME II. 
1043 
Cellulitis, pelvic, after gonor- 
rhoea, 740. 
after lithotomy, 680. 
causes of, 817. 
data from digital examina- 
tion, 818. 
diagnosis from extra-uterine 
pregnancy, 832. 
from myo-fibromata, 768. 
frequency of, 817. 
peritonitis in, 819. 
prognosis in, 818. 
symptoms of, 818. 
terminations of, 818. 
treatment of, 819. 
peri-uterine, 817. 
Cementum, exostosis from, 937. 
Cerebral symptoms after spine 
injuries, 857. 
Cerebro-spinal causes of impo- 
tence, 601. 
irritation, priapism in, 437. 
Chancre, complicating gonor- 
rhoea, 469. 
of labia, diagnosis from epi- 
thelioma of, 721. 
pbagedaenic, vesico-vaginal 
fistula from, 742. 
Charriere's forceps, 85. 
Cheesy deposits in prostate, 506. 
Chest penetrated by humerus, 
66. 
Chilblain, 420. 
Children, lithotomy in, 674, 693. 
Chloroform, 286. 
alarming brain, heart, and 
lung symptoms under, 
288. 
treatment of, 288. 
as heart-depressant, 283. 
compared with ether, 290. 
danger of, in structural 
changes in heart, 283. 
deaths from, 291. 
mode of administration, 287. 
phenomena attending admin- 
istration, 287. 
physiological action of, 287. 
pulse-tracing under, 291. 
use of, when ether fails, 291. 
Cholesterin in antracele, 959. 
Chordee in gonorrhoea, 466. 
hemorrhage in, 468. 
treatment of, 466. 
Chorea of pharynx, 1004. 
Cicatricial contractions after 
burns, 416. 
relieved by lateral approxi- 
mation of sound skin, 419. 
stenosis of oesophagus, 1019. 
of phary nx, 1012. 
Cicatrix, keloid degeneration of, 
416. 
malignant disease in, 417. 
sensitive, 417. 
treatment of, after burns, 419. 
Circocele, 562. 
Circumcision in phimosis, 427. 
in preputial concretions, 425. 
Levis's forceps in, 429. 
methods of, 428. 
Clavicle, dislocations of, 46. 
excision of, 246. 
of end in dislocation of, 49. 
Cleanliness of person in oper- 
ating, 272. 
Clergymen's sore throat, 1006. 
Clitoridectoray for epilepsy, 724. 
Clitoris, hypertrophy of, 723. 
removal by pin and ligature, 
724. 
wounds of, 723. 
Clove-hitch in dislocations, 25. 
Club-foot, hydronephrosis with, 
703. 
simulated in phimosis, 427. 
Coccyx, dislocation of, 88. 
excision of, 89. 
neuralgia of, 88. 
Coitus, excessive, irritable testis 
from, 595. 
fracture of penis during, 436. 
phimosis interfering with, 
427. 
prevented by hymen, 725. 
Cold, action of, 421. 
as local anesthetic, 291. 
Colic, renal, 707. 
Colpo-cystotomia, 695. 
Complicated dislocations, 28. 
Compound dislocations, 28. 
pulley in dislocations, 25. 
Compression of hypertrophied 
tongue, 906. 
of spinal cord, 845. 
Concretions in urethra, 453. 
simulating calculus, 644. 
vesical, complicating lithot- 
omy, 675. 
Concussion, cerebral, diagnosis 
from spine injury, 858. 
of joints, 132. 
of spinal cord, 842. 
Congenital deformities of blad- 
der, 609. 
of lip, 889, 897. 
of urethra, 450. 
dislocations, 33. 
of hip, 106. 
of humerus, 67. 
of knee, 115. 
• of lower jaw, 38. 
of patella, 111. 
Conjunctiva, congested, in spine 
injuries, 856. 
Constipation in dislocation of 
coccyx, 89. 
Contusions of joints, 131. 
of labia, 717. 
of penis, 424. 
of scrotum, 515. 
Convulsions from phimosis, 427. 
in burns, 417. 
in child, from teeth, 923. 
in renal colic, 707. 
in spine injuries, 855. 
Cooper's method in dislocation 
of hip, 99. 
Copaiba, rash from, 466. 
Coraco-humeral ligament in 
luxations, 59. 
Corpus spongiosum, wounds of, 
439. 
Corrosive sublimate poisoning, 
1033. 
Counter-irritants in articular 
disease, 200, 202. 
in coxalgia, 178. 
in epididymitis, 583. 
Counter-irritation by multi- 
puncture, 265. 
Cowper's glands, inflammation 
of, 467. 
Coxalgia, 162. 
abscess in, 166. 
Adams's operation for, 184. 
Coxalgia, anchylosis delayed in, 
175. 
arching of spine in, 163. 
author's splint in, 175. 
causes, exciting, 168. 
predisposing, 167. 
cuirass in, 230. 
Davis's splint in. 179. 
deformity in, 166. 
diagnosis from abscess, psoas, 
172. 
from arthritis, sacro-iliac, 
197. 
from bursitis, psoas anl 
iliac, 173. 
from diastasis, 173. 
from dislocations, 93, 171. 
from Pott's disease, 172. 
from pseudarthritis, 205. 
from rheumatism, 173. 
from sacro-iliac disease, 
172. 
elevation of pelvis in, 164. 
evening pain in, 163. 
fibrous anchylosis in, 183. 
frequency of, 163. 
gluteo-femoral groove in, 163. 
hectic fever in, 165. 
location of pain in, 163. 
malpositions corrected in, 176. 
necrosed acetabulum in, 186. 
pathology, differentiation be- 
tween osteal jind synovia 1, 
168. 
of incipient, 168. 
of old, 169. 
position of limb in, 163. 
prognosis, age in, 173. 
coexistence of organic dis- 
ease in, 174. 
mode of onset in, 174. 
sequel of acute fevers in, 
174. 
structures involved in. 174. 
resolution prevented in, 175. 
Sayre's splint in, 180. 
shortening in, 166. 
stiffness in, 163. 
symptoms contrasted, 167. 
explained, 165. 
of first stage, 163. 
of second stage, 164. 
of third stage, 166. 
treatment of, 175. 
by ablation, 186. 
by excision, 184. 
age influencing, 185. 
amount removed in, 186. 
periosteum preserved in, 
186. 
by immobilization, 175. 
constitutional, 178. 
osteotomy in, 183. 
steel splint in, 175. 
tenotomy in, 183. 
walking splints condemn' di 
in, 175. 
without splints, 178. 
with Pott's disease, 884. 
Coxo-femoral anchylosis, caus- 
ing lordosis, 868. 
joint, amputation of,.372. 
dislocation of, 89. 
excision of, 228. 
Cramp of jaw, 38. 
Crepitation in arthritis, 1'52. 
in dislocations, 20. 
Croup, anaesthetics in, 283. 1044 
INDEX TO VOLUME II. 
Cryptorches, virility of, 603. 
Cuboid bone, dislocation of, 125. 
excision of, 260. 
Cuirass in excision of hip, 230. 
Cuneiform bones, dislocation of, 
125. 
excision of, 260. 
Curvature of penis, 437. 
of spine, 859. 
Cyphosis, 866. 
Cystic tumors of back, 840. 
of lower jaw, 940, 955. 
of ovary, 793. 
of scrotum, 519. 
of testis, 593. 
of vagina, 737. 
of vulva, 723. 
Cystine in urine, 628. 
Cystitis, 526. 
acute, 526. 
causes of, 526. 
diagnosis from prostatitis, 
527. 
pathology of, 528. 
strangury in, 528. 
symptoms of, 527. 
treatment of, 528. 
after gonorrhoea, 740. 
after lithotomy, 680. 
after lithotrity, treatment of 
debris in, 660. 
chronic, 528. 
catheterization in, 529. 
causes of, 528. 
causing calculus, 632. 
cystotomy in, 531. 
in female, 827. 
medicated injections in, 
530. 
prognosis in, 529. 
symptoms of, 529. 
treatment of, 529. 
diagnosis from prostatitis, 
495. 
from prostatorrhoea, 499. 
in calculus, 647. 
in gonorrhoea, 468. 
in hypertrophy of prostate, 
502. 
micturition in, 527. 
nephritis after, 698. 
neuralgia of testis in, 596. 
pyelitis after, 699. 
retained urine in, 510. 
sex in, 527. 
tenesmus in, 527. 
treatment of, 528, 529, 827. 
Cystocele, vaginal, 610. 
diagnosis of, 611. 
from prolapsus vaginae, 
736. 
treatment of, 611. 
Cysto-fibromata of uterus, 773. 
Cystoma. See Cynt«. 
Cystorrhoea, 528. 
Cystotomia epigastrica, 690. 
Cystotomy for cystitis, 531. 
Cysts, dentigerous, 938. 
dermoid, 813. 
diagnosis from hydronephro- 
sis, 704. 
of broad ligament, 812. 
of kidney, 708. 
of lip, 893. 
of lower jaw, 940, 955. 
of ovary, 793. 
of prostate, 506. 
of soft palate, 984. 
Cysts of tongue, 911. 
parasitic, of tonsil, 985. 
renal, 708. 
Dislocations, anatomical knowl- 
edge in, 17, 24. 
asymmetry in, 20. 
bony deposits in unreduced, 
22. 
causes of, 19. 
classification and definition 
of, 17. 
bilateral, 18. 
complete, 17. 
complicated, 18. 
congenital, 18. 
consecutive, 18. 
double, 18. 
incomplete, 17. 
old, 18. 
pathological, 17. 
primitive, 18. 
recent, 18. 
secondary, 18. 
simple, 18. 
single, IS. 
traumatic, 17. 
unilateral, 18. 
complicated with fracture, 28. 
compound, 28. 
conditions for amputation 
in, 29, 295. 
for excision in, 29. 
dangers of, 28. 
dressings for, 29. 
irrigation in, 29. 
sequelae of, 30. 
tenotomy in, 29. 
treatment of, 28. 
with epiphyseal separation, 
30. 
congenital, 33. 
causes, foetal, 33. 
nervous, 33. 
traumatic, 33. 
overlooked, 33. 
treatment of, 33. 
crepitus in, 20. 
diagnosis from epiphyseal 
separation, 20. 
from fractures, 20. 
from sprains, 131. 
disability after, 22. 
discoloration in, 20. 
during delivery, 33. 
frequency of, compared with 
fractures, 17. 
from muscular weakness, 19. 
function lost in, 20. 
in coxalgia, 170. 
numbness in, 19. 
old, 31. 
accidental fracture in, 32. 
conditions influencing re- 
duction of, 31. 
sequela; of, 32. 
treatment of, 32. 
preliminary, 31. 
overlooked, 17. 
pain in, 19. 
passive motion in, 28. 
pathological effects of, 21. 
position of limb in, 20. 
prognosis in old, 22. 
in recent, 22. 
pseudarthrosis in unreduced, 
21. 
sex in, 19. 
shortening in, 20. 
spontaneous, in sterno-clavic- 
ular ai thritis, 199. 
statistics of, 19, 28. 
D. 
Davy's lever, 372. 
Death from chloroform, 291. 
from ether, 291. 
from pain, 274. 
Deformities after burns, 416. 
amputation in, 296, 420. 
of lip, 889, 897. 
of spine, 859. 
Degeneration of cartilages, 147. 
of stump, 323. 
Deglutition affected in Pott's 
disease, 873. 
in spine injuries, 856. 
Delirium after spine injuries, 
857. 
hysteroid, after operations, 
278. 
tremens after operations, 268. 
Dental caries, 927. 
denudation, 926. 
fistula, 929. 
necrosis, 927. 
pulp, exostosis from, 938. 
Dentigerous cysts, 938. 
changes of jaw in, 938. 
statistics of, 943. 
treatment of, 939. 
osteomata, 910. 
Dentine, exostosis from, 938. 
Dermoid cysts, 813. 
contents of, 813. 
of back, 840. 
of testis, 598. 
Diabetes, pruritus vulvae from, 
724. 
Diarrhoea in white swelling, 186. 
treatment of. in burns, 417. 
Diastasis, diagnosis from coxal- 
gia, 173. 
Diet after operations, 274. 
after ovariotomy, 810. 
Digital examination in coxal- 
gia, 184. 
in hip dislocations, 94. 
of bladder after lithotomy, 
688. 
Dilatation in phimosis, 427. 
of prostate in lithotomy, 673. 
of urethral stricture, 483. 
Diphtheria, avoided before oper- 
ating, 272. 
diagnosis from erysipelas, 408. 
Diphtheritic paralysis, 1007. 
pharyngitis, 1007. 
Disability after anchylosis, 142. 
af ter dislocations, 22. 
Discoloration in dislocatiosn, 
20. 
Diseases, constitutional, of spe- 
cial joints, 162-205. 
of bones, amputation for, 294. 
of joints, after sprains, 131. 
amputation for, 295. 
of soft parts, amputation for, 
293. 
Dislocations, 17-126. 
after articular disease, 19. 
after-treatment of, 27. 
age in, 19. 
anaesthetics in, 24, 43, 59, 
63. INDEX TO VOLUME II. 
1045 
Dislocations, symptoms of, 19. 
swelling in, 20. 
treatment, by manipulation, 
23. 
force in, 24-27. 
tenotomy in, 27. 
upon cadaver, 19. 
Dislocations, special, 34-126. 
atlo-axoid, 44. 
fracture of odontoid process 
in, 44. 
instantaneous death in, 44. 
rupture of odontoid liga- 
ment in, 44. 
spontaneous, 44. 
symptoms of, 44. 
treatment of, 44. 
chondral, 39. 
chondro-sternal, 39. 
costo-chondral, 39. 
costo-vertebral, 38. 
multiple injury in, 38. 
coxo-femoral, 89. 
intra-uterine, 33. 
metacarpo-phalangeal, 86. 
occipito-atloid, 43. 
of ankle, 116. 
compound, 119. 
of astragalus, 121. 
backward, 122. 
forward, 121. 
irreducible, 123. 
compound, ablation in, 
123. 
disability after, 123. 
excision in, 123. 
tenotomy in, 122. 
treatment of, 122. 
unusual, 124. 
of carpal bones, 81. 
anatomical barrier to, 81. 
of second row, 82. 
treatment of, 81. 
of carpus, 78. 
backward, 78. 
compound, 80. 
rules for treating, 80. 
congenital, 80. 
diagnosis from fractures, 
80. 
forward, 79. 
passive motion after, 79. 
treatment of, 79. 
with fracture, 78. 
of cartilages, semilunar, 114. 
reduction of, anaesthetics 
in, 114. 
of clavicle, 46. 
at acromial articulation, 50. 
at sternal articulation, 46. 
backward, 48. 
forward, 46. 
pathological, excision in, 
49. 
upward, 49. 
simultaneous, of both ends, 
49. 
treatment of, 47-50. 
of coccyx, 88. 
neuralgia after, 88. 
treatment of, 89. 
of elbow, 70. 
complications in, 74. 
compound, 76. 
partial excision in, 76. 
of ensiform cartilage, 40. 
of fibula, 120. 
lower end of, 121. 
Dislocations, special: 
of fibula, upper end of, 120. 
of fingers, 86. 
of foot, 116. 
backward, 117. 
fracture-box in, 117. 
compound, 119. 
immobility in, 120. 
irrigation in, 120. 
forward, 116. 
inward, 118. 
outward, 117. 
with Pott's fracture, 117. 
tenotomy in, 117. 
treatment of, 116-120. 
upward, 119. 
of forearm, 67. 
of hand, 78. 
of hip, 89. 
accidents attending reduc- 
tion of, 106. 
after-treatment of, 98. 
anaesthetics in, 94. 
anomalous, 102. 
Bigelow's classification of, 
91. 
causes of, 91. 
complications in, 105. 
congenita], 106. 
sex in, 106. 
symptoms overlooked in, 
107. 
treatment, wheel-crutch 
in, 107. 
diagnosis, from coxalgia, 
93, 171. 
from fracture, 92, 99,100. 
difficulties of reduction in, 
90. 
Y ligament in, 91. 
downward, 102. 
downward and forward, 98. 
forward, 102. 
fracture of acetabulum 
with, 105. 
of femur with, 105. 
frequency of, compared 
with fracture, 89. 
iliac, 91. 
ilio-sciatic, 93. 
infra-cotyloid, 102. 
ischiatic, 93. 
arching of back in, 94. 
manipulation in reduction 
of, 94, 99, 101. 
obturator, 98. 
anatomical explanation 
of, 99. 
old, conditions unfavorable 
to reduction of, 105. 
treatment of, 106. 
partial or incomplete, 104. 
pubic, 100. 
femoral vessels in, 100. 
reduction of, 94, 99, 101, 
106. 
secondary dislocations of, 
98, 99. 
subpubic, 102. 
supra-cotyloid, 102. 
upward, 102. 
upward and backward, 91, 
93. 
upward and forward, 100. 
varieties of, 89. 
relative frequency of, 90. 
of humerus, 53. 
abscess, diffuse in, 66. 
Dislocations, special: 
of humerus, after-treatment 
of, 62. 
anatomical knowledge in, 
59. 
arteries, ruptured in reduc- 
tion of, 65. 
auscultation in diagnosis 
of, 65. 
axillary, 53. 
backward, 55, 
chest penetrated in, 66. 
complications in, 64. 
compound, 66. 
congenital, 67. 
diagnosis from epiphyseal 
separation, 58. 
from fracture, 58. 
downward, 53. 
forward, forms of, 54. 
fracture in, reduction of, 65. 
of glenoid cavity in, 66. 
of ribs in, 66. 
simultaneous with, 66. 
frequency of, 53. 
injury of nerves in, 65. 
laceration of axillary ves- 
sels in, 65. 
old, unreduced, 64. 
anaesthetics in, 64. 
force in, 64. 
manipulation in, 64. 
operations in, 64. 
rupture of axillary artery 
in, 64. 
overlooked, 58. 
partial, or sub-, 55. 
after chronic arthritis, 
56. 
passive motion in, 62. 
signs, common in, 56. 
of varieties, contrasted, 
58. 
simultaneous, of both, 67. 
subcl avicul ar, 54. 
subcoracoid, 54. 
secondary, 54. 
subglenoid, 53. 
subspinous, 55. 
treatment of, 59. 
by arm at a right angle, 
61. 
by arm parallel to head, 
61. 
by Cooper's method, 62. 
by extension and coun- 
ter-extension, 60. 
by heel in axilla, 60. 
by manipulation, 59. 
by pulleys, 62. 
by Smith's method, 62. 
complications in, 64. 
varieties of, 53. 
of inferior maxilla, 34. 
after-treatment of, 37. 
bilateral, 35. 
causes of, 34. 
congenital, 38. 
absence of facial symme- 
try in, 38. 
diagnosis of, 36. 
forms of, 34. 
mechanism of, 34. 
prognosis in, 36. 
statistics of, 34. 
sub-, 36. 
complete, spontaneous 
after, 37. 1046 
INDEX TO VOLUME II. 
Dislocations, special: 
of inferior maxilla, treatment 
of, 37. 
unilateral, 35. 
symptoms, absence of, 35. 
of knee, 111. 
anatomical obstacle to, 111. 
backward, 112. 
disease as a cause of, 112. 
complicated, 115. 
compound, 115. 
congenital, 115. 
recurrence of, tenotomy 
in, 115. 
disability after, 113,114. 
external rotatory, 114. 
forward, 111. 
fracture in, 115. 
joint-exposure in, 115. 
lateral, 113. 
ligaments lacerated in, 111, 
113. 
treatment of, 112-115. 
vessels lacerated in, 115. 
of metacarpal bone of thumb, 
82. 
of metacarpus, 82. 
of metatarsus, 125. 
irreducible, usefulness after, 
126. 
treatment of, 126. 
of os calcis, 124. 
of os cuboides, 125. 
of os cuneiforme, 125. 
of os magnum, 81. 
during parturition, 81. 
of os pisiforme, 81. 
of os scaphoides, 125. 
of os semilunare, 81. 
of ovaries, 784. 
of patella, 107. 
after-treatment of, 110. 
anatomical relations in, 107. 
axial, 109. 
congenital, 111. 
diagnosis from fracture, 
111. 
inward, 109. 
muscular action as a cause 
of, 108, 111. 
outward, 107. 
reduction, difficulty in, 110. 
rupture of ligamentum pa- 
tellie as a cause of, 110. 
treatment of, 109, 111. 
upward, 110. 
vertical, 109. 
of pelvic bones, 87. 
after-effects of, 88. 
catheterization in, 88. 
treatment of, 88. 
of penis, 437. 
of phalanges, 87. 
of radius and ulna, 70. 
backward, 70. 
diagnosis from fracture of 
humerus, 71. 
period when irreducible, 
72. 
complications in, 74. 
forward, 74. 
fractures with, 74. 
lateral, 75. 
inward, 75. 
outward, 75. 
postero-lateral, 75. 
irreducible, 76. 
tenotomy in, 73. 
Dislocations, special: 
of radius and ulna, treatment 
of, 73, 75, 76. 
of ribs, 38. 
of ribs and costal cartilages, 
38. 
of scapula, 50. 
downward, 50. 
of inferior angle of, 52. 
treatment of, 51, 52. 
upward, 51. 
of shoulder, 46. 
of sternal bones, 39. 
treatment of, 40. 
of tarsus, 121. 
of tendon of biceps flexor cu- 
biti, 67. 
of thigh, 89. 
of thumb, 83. 
excision in old cases of, 85. 
of first phalanx, backward, 
83. 
pathology of, 83. 
reduction, mechanical 
difficulty in, 85. 
of first phalanx, forward, 
86. 
of second phalanx, 86. 
of toes, 126. 
compound, amputation or 
excision in, 126. 
great, irreducibility of, 126. 
treatment of, 126. 
of tooth, 926. 
of ulna from humerus, 70. 
of vertebrae, 40. 
above second cervical, 43. 
below second cervical, 42. 
injury to spinal cord in, 
42. 
catheterization in, 45. 
cervical, 41. 
dorsal, 45. 
fracture with, 40, 45. 
paralysis in, 43, 45. 
prevention of bed-sores in, 
46. 
treatment of, 43, 45. 
of wrist, 78. 
perinea], 103. 
peroneo-tibial, 120. 
radio-humeral, 68. 
backward, 69. 
forward, 68. 
irreducible, period when, 
69. 
usefulness after, 69. 
outward, 70. 
overlooked, 68. 
treatment of, 68, 70. 
with fracture of interna) 
condyle, 69. 
radio-ulnar, inferior end, 77. 
backward, 77. 
forward, 77. 
fracture with, 77. 
partial, 77. 
treatment of, 77. 
subastragaloid, 123. 
of tetnporo-maxillary joint, 
17, 37. 
tibio-femoral, 111. 
Displacement in dislocations of 
vertebrae, 42, 44, 45. 
of ovaries, 784. 
of uterus, 753. 
Distoina haematobium in kid- 
ney, 709. 
Dorsal vertebrae, dislocations of, 
45. 
Drainage by twisted oakum, 
192. 
in wounds of joints, 136. 
of ovarian cysts, 802. 
Drainage-tube in amputations, 
314, 373. 
in ankle disease, 192. 
in Caesarean section, 822. 
in compound dislocation of 
wrist, 80. 
in coxalgia, 184. 
in excisions, 213,218, 222. 
in gastrotomy, 835. 
in nephrotomy, 713. 
in operations, 274. 
in ovariotomy, 810. 
in pelvic cellulitis, 820. 
in spinal abscess, 884. 
in white swelling, 190. 
Dressing-carriage, Morton and 
Hart's, 275. 
Dressing of amputations, 316. 
Dropsy of antrum, 958. 
of Fallopian tube, 812. 
of joints, 139. 
ovarian, diagnosis of, 796. 
Duodenal ulcer in burns, 415. 
Dynamometer in dislocations, 
27. 
Dysmenorrhoea, 765. 
from polypi, 774. 
from uterine flexions, 760. 
treatment by dilatation, 765. 
by oophorectomy, 785. 
Dyspermatism, 603. 
Dysphagia in dislocation of 
clavicle, 48. 
in occipito-atloid arthritis, 
196. 
in paralysis, 1027. 
nervous, 1004. 
Dyspnoea in dislocation of clavi- 
cle, 48, 49. 
in luxations of sternum, 40. 
in spine injuries, 43, 856. 
Dysuria in gonorrhoea, 461. 
in preputial concretions, 425. 
E. 
Eburnation, 157. 
Echinococci in kidney, 709. 
Ecrasement of myo-fibromata. 
771. 
of tongue, 915. 
of uterine carcinoma, 779. 
„ polypi, 775. 
Ecraseur, 915. 
Eczema from phimosis, 427. 
of penis, 426. 
of scrotum, 515. 
Effusion in white swelling, 
187. 
Elastic armlet in luxations, 77. 
bands in congenital disloca- 
tions, 3.3. 
ligature in meningocele, 888. 
Elbow, amputation at, 76, 342. 
anchylosis of, 143. 
compound dislocation of, 28, 
76. 
excision of. 76, 216. 
strumous arthritis of, 200. 
Electricity in chloroform narco- 
sis, 288. INDEX TO VOLUME II. 
1047 
Electrolysis in myo-fibromata, 
769. 
Elephantiasis of labia, 720. 
Elephantiasis scroti, 521. 
hernia in, 524. 
mortality of, 523. 
mortification from weight of, 
523. 
pathology of, 522. 
treatment of, 523. 
Elongation of cervix uteri, 780. 
of uvula, 981. 
Elytrotomy, 823. 
Emaciation in traumatic fever, 
393. 
Embolic theory of traumatic 
fever, 387. 
Embolism after operations, 277. 
during shock, 378. 
of penis, 469. 
Embryotomy from renal cyst ob-' 
structing labor, 709. 
Emesis after anaesthetics, 286. 
Emetics in erysipelas, 410. 
Emphysema of scrotum, 517. 
Empyema, diagnosis from Pott's 
disease, 876. 
Enamel, abrasion of, 926. 
nodules of, 937. 
Encephalocele. 886. 
treatment of, 888. 
Encephaloid of back, 839. 
of bone, 295. 
of lower jaw, 957. 
of prostate, 506. 
of testis, 590. 
of upper jaw, 961. 
Enchondroma, amputation in, 
295. 
of lower jaw, 956. 
of ovary, 814. 
of scrotum, 520. 
of submaxillary gland, 995. 
of testis, 594. 
of tongue, 912. 
of upper jaw, 963. 
Encysted calculus, 644. 
hydrocele, 560. 
Endometritis after gonorrhoea, 
740. 
Ensiform cartilage, dislocation 
of, 40. 
Entozoa in bladder, 538. 
in kidney, 709. 
in testis, 598. 
Enuresis, 543. 
Epicystotomia, 690. 
Epididymitis, 581. 
from urethral stricture, 584. 
hydrocele after, 570. 
in gonorrhoea, 469. 
side mostly affected in, 581. 
sterility after, 583, 603. 
thickening after, 582. 
treatment of, 582. 
Epilepsy, anaesthetics in, 283. 
clitoridectomy for, 724. 
dislocations in. 19. 
Epiphyses, exfoliation of, in ar- 
ticular disease, 201. 
separation of, diagnosed from 
luxation, 58. 
softening of, 158. 
Epiphysitis in ankle disease, 
191. 
Episiorrhaphy in vesico-vaginal 
fistula, 748. 
Epispadias, 452. 
Epispadias, absence of sym- 
physis pubis in, 452. 
treatment of, 452. 
Epithelioma of back, 839. 
of bladder, 548. 
of gums, 923. 
of labia, 721. 
of lip, 894. 
of oesophagus, 1019. 
of prepuce, 432. 
of scrotum, 525. 
of tongue, 912. 
of tonsil, 993. 
of vagina, 737. 
Epithelium in urine, 620. 
Epulis, 923. 
Erectile tumors of back, 839. 
of gums, 922. 
of lips, 892. 
of tongue, 911. 
Eruptions, syphilitic, on back, 
837. 
Erysipelas, 402. 
after wounds, 403, 409. 
alopecia after, 405. 
avoided before operating, 272. 
causes of, 402, 403. 
cellulo-cutaneous, 405. 
cutaneous, 404. 
diagnosis of, 408. 
from traumatic fever, 394. 
duration of, 406. 
erratic, 404. 
explanation of phenomena of, 
406. 
fatality of, 408. 
formation of pus in, 405. 
from contagion, 403. 
from infection. 403. 
hereditary influences in, 403. 
in compound dislocations, 
28. 
internal, 406. 
lymphatics involved in, 404, 
407. 
oedema in, 405. 
of fauces, 406. 
of larynx, 406. 
of pharynx, 406, 1008. 
of serous membranes, 406. 
of synovial membranes, 406. 
phlegmonous, 405. 
post-mortem appearances in, 
407. 
prognosis in, 408. 
epidemic influencing, 408. 
puerperal state predisposing 
to, 402. 
relapsing, 406. 
sloughing in, 405. 
spread of, 402. 
subcutaneous, 405. 
symptoms of, 404. 
treatment, general, 409. 
local, 411. 
prophylactic, 409. 
typhoid state in, 405. 
varieties of, 402. 
wounds changed by, 404. 
Erythema, diagnosis from ery- 
sipelas, 408. 
Esmarch's bandage in amputa- 
tions, 313. 
at hip, 372. 
double, 324. 
in excisions, 211, 217. 
of ankle, 241. 
Ether, 283. 
Ether, administration of, cau- 
tions during, 285. 
modes of, 284. 
phenomena attending, 284. 
after-effects of, 286. 
as heart tonic, 283. 
as local anaesthetic, 292. 
compared with chloroform, 
290. 
deaths from, 291. 
pulse tracings under, 290. 
Ethidene, 289. 
Exanthemata as a cause of ne- 
crosis, 950. 
pyelitis after, 699. 
ulceration of tonsil in, 991. 
Excision, 206. 
arrest of hemorrhage in, 212. 
beyond capsular ligament, 
212. 
conditions contra-indicating, 
207. 
during active inflammation, 
269. 
history of, 206. 
in arthritis, 152. 
strumous, 162, 190, 199. 
in compound dislocations, 29. 
in contiguity, 207. 
in continuity, 207, 251, 253. 
in coxalgia, 184. 
instruments for, 209. 
in wounds of joints, 136. 
length of bone removed in, 
214, 217, 234. 
medullary canal avoided in, 
212. 
of bones and joints, 206. 
periosteum preserved in, 186, 
230. 
re- or second, 212. 
repair after, 208. 
epiphyseal growth in, 209. 
reproduction of bone in, 
208. 
union by callus in, 208. 
rules for, 211. 
shortening after, 209. 
Excisions, special, 212-260. 
of ankle, 241. 
compared with amputation, 
244. 
dressing of, 242. 
Esmarch's bandage in, 241. 
immobilization of, with 
plaster, 242. 
in compound dislocations 
of, 120. 
lines of incision in, 241. 
results of, 243. 
subperiosteal, method of, 
242. 
of astragalus, 255. 
in irreducible dislocations 
of, 123. 
results of, 256. 
with calcaneum, 259. 
of bones of lower extremity, 
in continuity, 253-260. 
of calcaneum and astragalus, 
259. 
of clavicle, 246. 
usefulness of arm after, 
246. 
of clitoris, 724. 
of coccyx in dislocations, 89. 
of cuboid bone, 260. 
of cuneiform bones, 260. 1048 
INDEX TO VOLUME II. 
Excisions, special: 
of elbow, 216. 
amount removed in, 217. 
compared with amputation, 
218. 
in compound dislocations 
of, 76. 
in shot wounds of, 219. 
position in dressing, 218. 
prevention of anchylosis in, 
218. 
shape of incisions in, 217. 
subperiosteal method of, 
218. 
of femur, 253. 
at trochanter major, 253. 
of fibula, 255. 
functional importance of, 
255. 
of fingers, 225. 
of forearm, 252. 
results of, 252. 
usefulness after removal of 
one bone of, 252. 
of gums for angeiomata of, 
922. 
of hypertrophied, 919. 
of hand, portions of. 224. 
after-dressing of, 225. 
amputation preferred to, 
225. 
symmetry and function re- 
garded in, 224. 
of hip, 228. 
compared with amputation, 
231. 
compared with expectant 
treatment, 231. 
cuirass in, 230. 
incisions for, 228. 
methods to divide bone in, 
229. 
statistics of, 231. 
of humerus in continuity, 251. 
of jaws, 965. 
of knee. 233. 
amount removed in, 234. 
compared with amputa- 
tions, 237. 
deductions from statistics 
of, 239. 
direction of section in, 234. 
gravity of, 233. 
immobilization by plaster, 
236. 
incisions in, 234. 
in compound dislocations 
of, 115. 
influence of age upon, 239. 
in true anchylosis of, 146. 
removal of patella in, 235. 
tenotomy in, 235. 
of lipoma, 839. 
of lower jaw, 967. 
entire, 970. 
for necrosis, 953. 
for polycystic disease, 940. 
instruments for, 967. 
of lateral half of, 968. 
of middle of, 968. 
parotid gland in, 969. 
partial, 967. 
results of, 970. 
retraction of remaining 
half in, 970. 
of metacarpal bones, 225. 
of metacarpus, 226. 
ot metatarsal bones, 260. 
Excisions, special: 
of metatarsus in dislocation 
of, 126. 
of os calcis, 257. 
results of, 258. 
subperiosteal, 258. 
of parotid gland, 1001. 
of patella, 253. 
in resection of knee, 235. 
results of, 254. 
of phalanges, 225. 
of phalanx, ungual, 225. 
of ribs and their cartilages, 
227. 
dressing for, 227. 
of scaphoid bone, 260. 
of scapula, 248. 
after amputations at shoul- 
der-joint, 251. 
dressing for, 249. 
incisions for, 249. 
of acromion process of, 248. 
propriety of. for malignant 
disease, 251. 
results of, 249. 
subperiosteal method of, 
249. 
total, 248. 
of shoulder, 212. 
for shot wounds, 216. 
for strumous arthritis of, 
200. 
mortality compared with 
amputation, 216. 
proper period for, 216. 
shape of incision in, 214. 
statistics of, 215. 
usefulness of arm after, 214. 
with portions of clavicle 
and scapula, 216. 
of sternum, 226. 
of submaxillary gland, 996. 
of tarsal bones, 255-260. 
of tarsus, parts of, 260. 
of testis, after hmmatocele, 
580. 
for cancer, 591. 
for cystic disease, 594. 
for dermoid cysts of, 598. 
for enchondroma, 594. 
for sarcoma, 592. 
of tubercular, 589. 
of tibia, 254. 
after complicated fracture, 
254. 
functional importance of, 
254. 
results of, 254. 
union after, 254. 
of thumb, 225. 
in dislocations, compound, 
87. 
old, 85. 
of toes, 260. 
in dislocations of, 126. 
of tongue, 916. 
by buccal method. 918. 
by oral method, 916. 
by submental method, 917. 
by symphyseal division, 
916. • 
of hypertrophied, 906. 
of upper jaw, 970. 
for dentigerous cysts, 939. 
instruments for, 970. 
method of, author's, 971. 
Fergusson's, 971. 
Liston's, 970. 
Excisions, special: 
of upper jaw, method of, 
Lizars's, 970. 
of both, 972. 
orbital plate preserved in, 
972. 
partial, 973. 
results of, 973. 
of uterus, 780. 
of uvula, 982. 
of veins in varicocele, 567. 
of wrist, 220. 
compared with amputation, 
223, 224. 
drainage-tube in, 222. 
for disease of, 203. 
for shot wounds of, 224. 
Lister's method of, 221. 
mortality of partial and 
complete compared, 223. 
passive motion in, 222. 
preservation of tendons in, 
220. 
proper period for, 223. 
shape of incision in, 220. 
splint for, 222. 
Excrescence, specific, upon pe- 
nis, 438. 
upon vulva, 721. 
Exostoses, amputation for, 295. 
causing retention of urine, 
511. 
Exostosis of tooth, 937. 
Exstrophy of bladder, 611. 
Extension after amputations, 
319. 
in dislocations, 24, 33. 
in strumous arthritis, 161,177, 
187. 
External urethrotomy, 492. 
Extirpation of uterus, 780. 
Extra-uterine pregnancy, 829. 
Extravasation of blood in frac- 
ture of penis, 436. 
of urine, fatal, caused by 
stricture, 477. 
in wounds of urethra, 440. 
Eye, destroyed by abscess in 
antrum, 958. 
effect of nerve-injury upon, 
856. 
F. 
Face, deformities of, 889, 897. 
Facets of calculi, 633. 
Fallopian tube, dropsy of, 812. 
False anchylosis, 141. 
joints, 21, 32. 
passages in urethra, 440, 487. 
Fascia, importance of, in lithot- 
omy, 666. 
Fatty degeneration of stump, 
323. 
tumor of back, 838. 
Fauces, affections of, 981. 
erysipelas of, 406, 1008. 
Fecal impaction, diagnosis from 
myo-fibroma, 768. 
Female catheter, 555. 
Females, calculus in, 693. 
dilatation of urethra of, 549. 
diseases of external genitals 
of, 716-726. 
gonorrhoea in, 738. 
hair upon lip of, 891. 
irritable bladder of, 828. 
lacerated perineum of, 726. INDEX TO VOLUME II. 
1049 
Females, lithotomy in, 693. 
lithotrity in, 694. 
uterine disease in, 750, 782. 
vesico-vaginal fistula in, 740. 
Femur, amputation of, 368. 
caries of, in coxalgia, 169. 
changes of, in incipient cox- 
algia, 168. 
diagnosis of fracture of, 93. 
excision in continuity of, 253. 
fracture of, in anchylosis, 143. 
in dislocations, 106. 
separation of head of, 170. 
Fever, inflammatory, in burns, 
414. 
traumatic infective, 383. 
secondary, 385. 
urethral, 444. 
Fibrinous concretions, 640. 
Fibroid tumors. See Fibroma. 
Fibroma of back, 839. 
of bladder, 546. 
of gullet, 1025. 
of lip, 894. 
of lower jaw, 955. 
of ovary, 813. 
of scrotum, 520. 
of soft palate, 985. 
of synovial membrane, 147. 
of testis, 595. 
of tongue, 911. 
of upper jaw, 962. 
of vagina, 737. 
of vulva, 722. 
papillary, as cause of htema- 
turia, 540. 
Fibro-vascular growth of gums, 
922. 
Fibula, dislocations of, 120. 
excision of, in continuity, 255. 
Filiform bougie, 486. 
Fingers, amputation of, 333. 
supernumerary, 296. 
dislocations of, 86. 
excision of, 225. 
Fissure of lip, 897. 
of palate, 974. 
of tongue, 908. 
of vagina, 736. 
Fistula after lithotomy, 681. 
dental, 929. 
in antrum, 959. 
inguinal, 537. 
in cesophagus, 1018. 
in pharynx, 1011, 
in urethra, 446. 
recto-vesical, 536. 
after lithotomy, 679. 
treatment of, 536. 
salivary, 998. 
urethro-rectal, 449. 
urethro-vaginal, 743. 
utero-vesical, 749. 
vesical, after pelvic abscess, 
820. 
incontinence in, 544. 
vesico-pubic, 537. 
treatment of, 537. 
vesico-utero-vaginal, 750. 
vesico-vaginal, 740. 
caused by calculus, 647. 
Flaps, varieties of, for amputa- 
tions, 300. 
Flexion in white swelling, 186. 
Flexions of uterus, 759. 
forms of, 759. 
signs of, 760. 
treatment, mechanical, 760. 
Flexions of uterus, treatment, 
operative, 761. 
Foetal tumors of back, 840. 
of scrotum, 598. 
Follicular inflammation in gon- 
orrhoea, 467. 
vulvitis, 719. 
Foot, amputations of, 353. 
dislocations of, 116. 
surgical anatomy of, 353. 
Force in dislocations, 24, 32. 
Forced catheterization, 512. 
Forceps, clamp, 433. 
lion, 211. 
lithotomy. 669. 
Museux, 914. 
oesophageal, 1016. 
phimosis, 427. 
Levis's, 429. 
producing vesico-vaginal fis- 
tula, 742. 
tooth, 932. 
urethral, 455. 
Forearm, amputation of, 341. 
evulsion of, in reducing luxa- 
tions, 31. 
excision of bones of, 252. 
Foreign bodies in lip, 894. 
in oesophagus, 1014. 
in pharynx, 1012. 
in tonsil, 985. 
in urethra, 453. 
Fox apparatus in dislocations, 
47, 49, 51. 
Fracture, accidental, in old lux- 
ations, 32. 
complicated, amputation in, 
294. 
excision of tibia in, 254. 
complicating dislocations, 28. 
false anchylosis after, 141. 
in anchylosis, 143. 
in old dislocations, 65. 
intra-uterine, 33. 
of acetabulum, diagnosis of, 
93. 
of condyles of humerus, 74. 
of coronoid process of ulna, 
74. 
of femur in dislocations, 106. 
of humerus, supra-condyloid, 
74. 
of jaw, union of, prevented by 
fang of tooth, 926. 
of olecranon in luxations, 74. 
to reduce dislocations of 
elbow, 73. 
of penis, 436. 
of tooth, 926. 
Pott's, with dislocation of 
ankle, 117. 
with dislocations of foot, 116, 
117. 
of knee, 115. 
of vertebrae, 40, 45. 
of wrist, 78. 
Fracture-box in compound dis- 
locations, 29. 
of ankle, 120. 
in dislocations of foot, 116, 
117, 119. 
of tarsus, 122. 
Fraenum linguae, short, 904. 
praeputii, absence of, 432. 
short, hemorrhage from, 
431. 
Frigorific mixture, 291. 
Frost-bite, 244). 
Function, loss of, in dislocations, 
20. 
Fungoid arthritis, treatment of, 
154. 
granulations in sacro-iliac 
arthritis, 197. 
Fungus of bladder, 547. 
of testis, 589. 
Furuneulus, 397. 
causes of, 397. 
core of, 398. 
diathesis, 397. 
frequency of, 397. 
symptoms of, 397. 
treatment, abortive, 398. 
upon back, 837. 
varieties of, 397. 
G. 
Gag for jaws, 914. 
Galvano-cautery in excision of 
tongue, 91a. 
Gangrene after embolism, 277. . 
hospital, amputation in, 296. 
propagation of, by air, 388. 
of hard palate, 979. 
of penis, 435. 
of vulva, 718. 
senile, non-amputation in, 
296. 
Gangrenous ulcer of gums, 920. 
Gastric irritability from teeth, 
923. 
Gastro-enteritis in burns, 415. 
Gastro-hysterotomy, 820. 
conditions demanding, 821. 
mortality' compared with cra- 
niotomy, 821. 
operation of, 821. 
Porro method of, 822. 
Gastrotomy for stenosis of gul- 
let, 1023. 
in extra-uterine pregnancy, 
834. 
Genital function, disorders of, 
600. 
Genitalia of female, malforma- 
tions of, 611, 716, 732. 
of male, malformations of, 
426, 450, 611. 
parasites upon, 516. 
Genito-urinary organs, injuries 
and diseases of, 424-715. 
Gilbert's rope windlass, 25. 
Ginglymoid joints, repair of, 22. 
Gland, Cowper's, inflammation 
of, 467. 
parotid, 997. 
sublingual, 993. 
submaxillary, 995. 
vulvo-vagina), 718. 
Glans penis, inflammation of, 
467. 
specific warts upon, 438. 
Gleet, 470. 
as sign of stricture, 478. 
contagiousness of, 470. 
deep injections in, 472. 
diagnosis from prostator- 
rhoea, 499. 
granular, 471. 
treatment of, 471. 
parts invaded by, 470. 
pin-head, 470. 
signs of, 470. 
structural changes in, 470. 1050 
INDEX TO VOLUME II. 
Gleet, treatment of, 470. 
by bougies, 474. 
by local cauterizing, 472. 
Globus hystericus, 1026. 
Glossitis, 907. 
mercurial, 907. 
treatment of, 907. 
Gluteo-femoral groove in cox- 
algia, 163. 
Gonorrhoea, 460. 
after-treatment of, 465. 
bubo after, 469, 739. 
causes of, 460. 
chordee in, 466. 
chronic tendency of, 463. 
complications in, 466. 
phimosis as, 427. 
consequences of, 470. 
diagnosis of, 462. 
duration of, 461. 
epididymitis after, 469, 581. 
frequency of stricture after, 
476. 
incubation-period of, 461. 
in females, 738. 
complications in, 739. 
diagnosis of, from leucor- 
rhoea, 738. 
parts affected in, 738. 
pruritus vulvre in, 724. 
symptoms of. 738. 
treatment of, 738. 
mode of making injections 
in, 464. 
nature of virus of, 460. 
orchitis after, 469, 584. 
pathology of, 462. 
priapism during, 465. 
retention of urine in, 510. 
sicca, 466. 
stages of, 461. 
symptoms of, 461. 
treatment, abortive, 462. 
curative, 463. 
Gonorrhoeal ophthalmia, 474. 
rheumatism, 474. 
course of, 474. 
diagnosis of, from true 
acute, 475. 
nature of, 474. 
treatment of, 475. 
warts on labia, 721. 
on penis, 438. 
Gorget in lithotomy, 672. 
Gouging of bone, 192. 
Granular gleet, 471. 
vaginitis, 740. 
Granulation tissue in arthritis, 
153. 
Gravel, 705. 
Gullet, 1014. See (Esophagus. 
Gum-boil, or alveolo-dental ab- 
scess, 928. 
Gum lancet, 924. 
Gummata of soft palate, 983. 
of tongue, 912. 
Gums, 919. 
arrest of hemorrhage from, 
924. 
epithelioma of, 923. 
section of bone in, 923. 
fibro-angeiomata of, 922. 
section of bone in, 922. 
fibrous growths of, 921. 
hypertrophy of, 919. 
artificial teeth as cause of, 
919. 
treatment of, 919. 
Gums, inflammation of, from 
eruption of teeth, 924. 
hyperaemia absent in, 924. 
treatment by lancing, 924. 
mercurial, treatment of, 920. 
papilloma of, 922. 
pulp tumors on, 921. 
treatment of, 922. 
sarcoma of, 923. 
absence of, in edentulous 
jaw, 923. 
section of bone in, 923. 
tartar under, 920. 
tumid, 919. 
treatment of, 920. 
ulcer of, sloughing, 920. 
treatment of, 921. 
Hare-lip, embryonic failure in, 
897. 
hydronephrosis with, 703. 
single, 898. 
time to operate for, 898. 
with cleft palate, 974. 
Hayward's treatment of knee 
disease, 190. 
Head, malformations of, 885. 
Headache after ether, 286. 
after spine injuries, 857. 
Healing of wounds upon the 
intemperate, 268. 
Heart after lightning-stroke, 
423. 
diseases of, anaesthetics in, 
283. 
effects of chloroform upon, 
287. 
examination of, before oper- 
ating, 269. 
impulse of, in spine injuries, 
856. 
Heat, effects of, 412. 
Hectic, diagnosis of, from trau- 
matic fever, 394. 
in coxalgia, 165. 
in struma, 160. 
in traumatic fever, 392. 
in white swelling, 186. 
in wounds of joints, 136. 
Hemorrhage after divulsion of 
stricture, 489. 
af'er lithotrity, 660. 
after ovariotomy, 810. 
arrest of, after amputation 
of penis, 436. 
after extraction of teeth, 
936. 
after fracture of penis, 436. 
after gangrene of penis, 
436. 
by hot water, 273. 
by ligature, 298, 300. 
from cervix uteri, 763. 
from clitoris, 723. 
from end of bone, 313. 
from gums, 924. 
from uterine incisions, 762. 
polypi, 777. 
in cancer of palate, 984. 
in cancer of tongue, 914. 
in carbuncles, 401. 
in excisions, 212. 
in lithotomy, 676. 
in myo-fibromata, 769. 
in phimosis, 428. 
in uranoplasty, 980. 
control of, in amputating, 313. 
during operations, 273. 
danger of, in wounds of the 
back, 838. 
death from, after circum- 
cision, 428. 
fatal, in old dislocations, 32. 
from inverted uterus, 764. 
from uterine polypi, 774. 
from wounds of labia, 717. 
in compound dislocations, 28. 
in compression of spinal cord, 
845. 
in operation for hare-lip, 900. 
in ruptured frsenum, 431. 
into bladder, after lithotomy, 
680. 
in varix of gullet, 1025. 
prevention of, 264. 
prostatic, 506. 
II. 
Haematoeele, 579. 
causes of, 579. 
diagnosis from cystic testis, 
593. 
from hydrocele, 573, 579. 
encysted, 580. 
hydro-, 580. 
of spermatic cord, 561. 
diffused, 561. 
encysted, 562. 
treatment of, 562. 
peri-uterine, 815. 
causes of, 815. 
diagnosis, differential, be- 
tween intra- and sub- 
peritoneal, 816. 
from extra-uterine preg- 
nancy, 833. 
from myo-fibromata, 768. 
prognosis in, 816. 
sequelae of, 817. 
source of blood in, 815. 
symptoms of, 815. 
treatment of, 816. 
pudendal, 717. 
structural changes in, 580. 
symptoms of, 579. 
treatment of, 580. 
upon back, 837. 
Haematuria, 537. 
causes of, 537. 
Bilharzia haematobia as, 
538. 
"coffee-grounds" urine in, 
539. 
diagnosis of, 538. 
in eancer of bladder, 548. 
in renal cancer, 711. 
in spine injuries, 841, 854. 
renal, 708. 
shape of clots in, 539. 
treatment of. 539, 708. 
Haemostatic, hot water as, 273. 
Hair misplaced, pruritus vulvas 
from, 725. 
upon lip of female, 891. 
Hairy moles of face, 891. 
Hand, amputation of, 338. 
dislocations of, 78. 
excision of portions of, 224. 
Hard palate, cleft in, 974. 
Hare-lip, 897. 
after-treatment of, 900. 
complications in, 898, 902. 
double, forms of, 901. 
complicated by prominent 
intermaxillary bone, 902. INDEX TO VOLUME II. 
1051 
Hemorrhage, recurrent, 277,318. 
renal, 708, 711. 
secondary, 278. 
after amputations, 320. 
amputation for, 65. 
ligation of common carotid 
for, 973. 
period of liability to, 278. 
urethral, 440. 
vesical, 537, 548. 
from distention, 507. 
vicarious, 538. 
Hemorrhoids caused by hyper- 
trophied prostate, 502. 
by urethral stricture, 479. 
cystitis from, 828. 
urethral, 826. 
vesical hemorrhage vicarious 
for, 538. 
Hereditary tendency to calculus, 
631. 
to strumous arthritis, 150, 
158. 
Hernia caused by hypertro- 
phied prostate, 502. 
diagnosis from dislocated 
ovary, 784. 
from fatty tumors of sper- 
matic cord, 558. 
from hydrocele in female, 
577. 
in male, 572. 
from retained testis, 569. 
from varicocele, 564. 
hydrocele of sac of, 577. 
in elephantiasis scroti, 524. 
in urethral stricture, 479. 
lumbar, diagnosis from peri- 
nephritis, 702. 
omental, diagnosis from hy- 
drocele, 560. 
testis, 588. 
with congenital hydrocele, 
561. 
with exstrophy of bladder, 
612. 
Herpes of penis, 425. 
praeputialis in gonorrhoea, 
469. 
Hey's amputation of foot, 356. 
Hip-joint, amputation at, 372. 
anchylosis of, 144. 
disease of, 162. See Coxalgia. 
dislocations at, 89-107. 
excision of, 228. 
osteo-arthritis of, 155. 
Histoid tumors, 813. 
Hot water as haemostatic, 273. 
Humerus, amputation of, 346. 
dislocations of, 53. 
excision in continuity of, 251. 
of head of, 212. 
Hydatid cysts, diagnosis from 
hydronephrosis, 705. 
Hydrarthrosis in chronic syno- 
vitis, 138, 139. 
Hydrocele, 570. 
causes of, 570. 
changes from injection into, 
575. 
characters of fluid in, 570. 
complications in, 578. 
congenital, 576. 
relation of, to peritoneum, 
576. 
diagnosis from cancer of tes- 
tis, 573. 
from cystic testis, 593. 
Hydrocele, diagnosis from hae- 
matocele, 573. 
from hernia, 572. 
from sarcocele, 573. 
from varicocele, 573. 
diseased testis in, 571. 
encysted, 571, 577. 
spermatozoa in, 571. 
treatment of, 577. 
infantile, 576. 
seton in, 576. 
in female, 577. 
diagnosis of, 577. 
treatment of, 578. 
inguinal, 577. 
light test in, 572. 
of hernial sac, 577. 
of round ligament, 814. 
of spermatic cord, 559. 
congenital, 561. 
hernia with, 561. 
treatment of, 561. 
diffused, 559. 
diagnosis from omental 
hernia, 560. 
treatment of, 560. 
encysted, 560. 
spermatozoa in, 560. 
treatment of, 561. 
of tunica vaginalis testis, 570. 
symptoms of, 572. 
treatment, palliative, 573. 
radical, 574, 578. 
Hydrocephalus externus, char- 
acteristics of, 886. 
treatment by tapping, 886. 
internus, characteristics of, 
885. 
Hydro-haematocele, treatment 
of, 580. 
Hydronephrosis, 703. 
causes of, 703. 
character of contents in, 704. 
diagnosis of, 704. 
prognosis in, 704. 
symptoms of, 704. 
treatment of, 705. 
Hydrops articuli, 138, 139. 
renalis, 703. 
tubarum, 812. 
Hydrorachis, 851. 
anatomy of, 851. 
contents in, 851. 
diagnosis of, 852. 
seat of, 851. 
symptoms of, 852. 
treatment by injection, 853. 
by operation, 853. 
Hydrosalpinx, 812. 
Hymen, diseases of, 725. 
occluding vagina, 733. 
preventing coitus, 725. 
Hyperaemia, absence of, in in- 
flamed gums, 924. 
in spine injuries, 856. 
Hyperaesthesia in spine injuries, 
855. 
of oesophagus and pharynx, 
1003. 
Hypertrophy of clitoris, 723. 
of hard palate, 978. 
of labia, 719. 
of lip, 890. 
of ovaries, 783. 
of penis, 426. 
of prostate, 499. 
of teeth, 937. 
of testis, 597. 
Hypertrophy of tongue, 905. 
of tonsil, 987. 
of upper jaw, 965. 
of uvula, 981. 
Hypodermic medication in 
burns, 417. 
Hypogastric operation for stone, 
664, 690. 
Hypospadias, 450. 
bifid scrotum in, 451. 
treatment of, 451. 
vesical irritation in, 451. 
Hysteria, diagnosis from Pott's 
disease, 876. 
from spine injury, 857. 
Hysterical delirium after oper- 
ations, 278. 
exhibitions after ether, 286. 
joint disease, 203. 
retention of urine, 511. 
Hysterotomy, 820. 
I. 
Ichthyosis linguae, 908. 
Idiocy, congenital dislocations 
with, 33. 
Idiosyncrasies influencing oper- 
ations, 269. 
Iliac abscess in Pott's disease, 
875. 
dislocation of hip, 91. 
Ilio-sciatic dislocation, 93. 
Ilium, caries of, diagnosis from 
sacro-iliac arthritis, 198. 
Immobilization, absolute, in 
joint-wounds, 135. 
in excisions, by plaster, 218, 
235, 242. 
Impacted calculi causing hy- 
dronephrosis, 703. 
Imperforate hymen, 733. 
vagina, 733. 
Impotence, 600. 
after lithotomy, 681. 
causes of, 600. 
pseudo-, or fictitious, 602. 
temporary, 602. 
treatment of, 602. 
Incipient coxalgia, pathology 
of, 168. 
Incised wounds of penis, 424, 
438. 
Incisions by puncture, 264. 
compound, 264. 
crucial, in anthrax, 401. 
fixation of skin during, 262. 
for excision of ankle, 241. 
of elbow, 217. 
of hip, 228 
of knee, 234. 
of scapula, 249. 
of shoulder, 214. 
of wrist, 220. 
for phimosis, 429. 
inspection of structures in 
making, 263. 
into joints, 129. 
of boils, 398. 
of deep tissues, 263. 
planning of, 263. 
simple, 264. 
use of director in, 263. 
uniform depth of, 262. 
Incomplete anchylosis, 141. 
dislocations, 17. 
Incontinence of urine, 543. 1052 
1NDEX TO VOLUME II. 
Incrustations, calcareous, upon 
retained catheter, 442. 
Indian basket in dislocations, 
25. 
India-rubber bands for exten- 
sion, 27. 
Infantile hydrocele, 576. 
Infarction of lungs, 389. 
Inferior maxilla, diseases of, 
946. 
Inflammation, dislocations af- 
ter, 19. 
of antrum, 957. 
of bladder, 526. 
of Cowper's glands after gon- 
orrhoea, 467. 
of glans penis after gonor- 
rhoea, 467. 
of gums, from teeth, 924. 
of joints, 150-203. 
of kidney, 698. 
of meninges of cord, 846. 
of ovary, 782. 
of parotid gland, 997. 
of penis, 434. 
of pharynx, 1005. 
of scrotum, 518. 
of synovial membrane, 137. 
of testis, 581. 
of tongue, 907. 
of tonsil, 985. 
of urethra, female, 825. 
male, 459. 
of vagina, 738. 
of velum palati, 983. 
of vulvo-vaginal glands, 718. 
Inflammatory fever, 385. 
peculiarities of tissues over 
spine, 837. 
Inguinal canal incised during 
castration, 600. 
hydrocele, 577. 
Inhalers for anaesthetics, 284. 
Injections in gonorrhoea, 462, 
464. 
in hydrocele. 575. 
in hydrorachis, 853. 
in ovarian cysts, 802. 
suspended in gonorrhoeal 
epididymitis, 582. 
Injury, amputation for, 293. 
Insomnia after spine injuries, 
857. 
Instruments, disinfection of, 
262. 
for amputations, 309. 
for excisions, 209. 
for lacerated perineum, 729. 
for lithotomy, 668. 
for lithotrity, 652, 658. 
for multipuncture, 265. 
for ovariotomy, 804. 
for vesico-vaginal fistula, 744. 
properly cleansed, 272. 
to avoid rusting of, 262. 
Insufflation in tonsillitis, 986. 
Intemperate, amputation in the, 
29. 
healing of wounds upon the, 
268. 
Intermaxillary bone in hare-lip, 
902. 
Intermediary period in ampu- 
tating, 297. 
Intermittent fever, diagnosis 
from traumatic, 394. 
Internal angular splint in com- 
pound dislocations, 30. 
Internal urethrotomy, 490. 
Intestines, vicarious work of, 
in burns, 417. 
Intra-uterine amputations, 326. 
dislocations, 33. 
Inunctions in syphilis, 587. 
Inversion of uterus, 763. 
Iodine, injection of, for hydro- 
cele, 575. 
in neglected sprains, 133. 
Iron in erysipelas, 410. 
Irrigation in compound disloca- 
tions, 29. 
of ankle, 120. 
Irritable bladder after gonor- 
rhoea, 475. 
in females, 828. 
testis, 595. 
Ischio-rectal fossa, abscess in, 
818. 
Itching of vulva, 724. 
Joints, movable bodies within, 
origin from ossifying car- 
tilage, 127. 
statistics of operations for, 
129. 
symptoms of, 128. 
treatment of, 129. 
nervous diseases of, 203. 
sprains of, 131. 
irritable joint after, 133. 
temporo-maxillary, noisy 
movements of, 17, 37. 
traumatic diseases of, 130. 
wounds of, 134. 
amputation or excision in, 
136. 
anchylosis after, position of 
limb for, 136. 
aspiration of pus in, 136. 
pyaemia fever in, 136. 
symptoms of, 134. 
synovitis after, 135. 
treatment by absolute im- 
mobilization, 135. 
J. 
Jarvis's adjuster, 27. 
Jaundice after shock, 378. 
in renal cancer, 712. 
Jaw, cramp of, 38. 
diseases of, 919. See Maxilla. 
dislocations of, 34. 
Joints, amputation, at ankle, 
358. 
at elbow, 342. 
at hip, 372. 
at knee, 365. 
at shoulder, 346. 
at wrist, 338. 
for disease and injury of, 
295. 
anchylosis of, 140-147. 
aspiration of, 162. 
cartilage degeneration in, 147. 
components of, 130. 
contusions of, 131. 
disease, of ankle, 190. 
of elbow, 200. 
of foot, 193. 
of hip, 162. 
of knee, 186. 
of sacro-iliac, 196. 
of shoulder, 199. 
of wrist, 202. 
simulated in phimosis, 427. 
dropsy of, 139. 
excision, of ankle, 241. 
of elbow, 216. 
of hip, 228. 
of knee, 233. 
of shoulder, 212. 
of wrist, 220. 
exposure of, in dislocations 
of knee, 115. 
inflammation of, 150. 
constitutional or strumous, 
154. 
anchylosis in, 150. 
seat of origin of, 150. 
theories concerning, 150. 
of synovial membrane of, 
137. 
irritable, 133. 
after contusions and 
sprains, 133. 
treatment of, 134. 
movable bodies within, 127. 
fibrinous, 127. 
Kidney, ablation of, 713. 
abscess of, 701. 
surrounding, 701. 
anomalies of, 696. 
Bright's disease of, with cal- 
culus, 647. 
calculus in, 705. 
changes produced by, 706. 
cancer of, 710.. 
changed in hypertrophied 
prostate, 503. 
cystic, 708. 
caused by urethral stric- 
ture, 482. 
destruction of, in hydrone- 
phrosis, 703. 
floating or movable, 696. 
causes of, 697. 
incarceration of, 698. 
symptoms of, 697. 
treatment of, 697. 
inflammation of, 698. 
parasitic disease of, 709. 
suppuration of, after calculus, 
647. 
tuberculosis of, 710. 
vicarious function of, in 
burns, 417. 
Knee-joint, amputation at, 365. 
anchylosis of, 145. 
disability, after dislocations 
of, 113, 114. 
disease of, 186. 
dislocations of, 28, 111. 
congenital, 115. 
excision of, 233. 
pain in, as a sign of coxalgia, 
163. 
Knife, author's lithotomy, 668. 
form of handle of, 262. 
keenness of, for precision, 262. 
manner of dividing parts 
with, 262. 
Neill's phalangeal, 333. 
positions of, in operating, 261. 
Knives, amputating, 309. 
Knock-knees favoring luxations 
of patella, 108. 
Knot, clove-hitch, 25. 
noose, 25. 
K. INDEX TO VOLUME II. 
1053 
K< Ipokleisis for vesico-vaginal 
fistula, 748. 
Ligaments, laceration of, in dis- 
locations of clavicle, 46. 
of elbow, 70. 
of hip, 95, 97. 
of humerus, 54. 
of knee, 111, 113. 
of vertebrae, 42. 
of wrist, 78. 
ruptured in coxalgia, 166. 
subcutaneous division of, 85. 
Ligamentum patellae, rupture 
of, 110. 
teres, intact in thyroid dislo- 
cations, 98. 
Ligation of arteries, 313. 
of axillary, 65. 
of carotid, common, 972. 
external, 1001. 
of digital, 334. 
of facial, 996. 
of popliteal, 367. 
perfect isolation of, 313. 
Ligature, animal, or catgut, 313, 
807, 821, 914. 
introduction of, 298, 300. 
Lightning-stroke, 423. 
heart after death from, 423. 
liquid blood after death from, 
423. 
paralysis after, 423. 
Limb, artificial, 327, 350, 365, 
371. 
amputation with reference 
to, 362. 
elongation of, in sacro-iliac 
arthritis, 197. 
mortification of, from press- 
ure, 411. 
Lingual abscess, 909. 
Lip, adenomata of, 893. 
angeiomatous naevi of, 892. 
carbuncle of, 892. 
chaps and cracks of, 890. 
contraction of, 889. 
cysts of, 893. 
epithelioma of, 894. 
causes of, 894. 
differential diagnosis of, 
895. 
frequency of, 894. 
symptoms of, 894. 
treatment of, 895. 
eversion and depression of, 
889. 
fibromata of, 894. 
fissure at commissures of, 903. 
of lower, 903. 
foreign bodies in, 894. 
hair upon female, 891. 
hypertrophy of, 890. 
treatment of, 891. 
lipomata of, 894. 
moles of, 891. 
myxomata of, 893. 
papillomata of, 893. 
restoration of lower, 896. 
of upper, 895. 
tumors of. 892. 
ulcer of, 890. 
wounds of, 891. 
treatment of, 892. 
Lipoma of back, 838. 
of lip, 894. 
of tongue, 911. 
of tonsil, 992. 
over parotid, 999. 
Liquid blood after death from 
lightning, 423. 
Lister's dressing, in amputa- 
tions, compared with the 
ordinary, 315. 
in compound dislocations, 
28, 29. 
in oophorectomy, 785. 
in ovariotomy, 807. 
method in excision of wrist, 
221. 
Lithectasy, 693. 
Lithic acid calculus, 623. 
Litholapaxy, 657. 
Lithotome cachg, 689. 
Lithotomy, 662. 
accidents during, 676. 
following, 679. 
after-treatment of, 675. 
arrest of hemorrhage in, 676. 
bilateral, 688. 
modifications of, 689. 
results of, 689. 
bladder, dilatation of neck in, 
673. 
opened beyond the prostate 
in, 679. 
causes delaying extraction in, 
674. 
causing sterility, 604. 
compared with lithotrity, 662. 
contra-indications for, 665. 
cystitis after, 680. 
digital examination of blad- 
der in, 672, 673. 
diphtheritic deposits in wound 
after, 681). 
extraction in, 673. 
laceration of prostate in, 
673. 
failure to enter the bladder in, 
678. 
fistula after, 681. 
hemorrhage into bladder af- 
ter, 680. 
high operation of, 690. 
history of, 663. 
in children, 674. 
anatomy in, 674. 
difficulties in, 674. 
incontinence of urine after, 
681. 
incrustation of wound after, 
682. 
in females, 694. 
urethral, 694. 
incontinence of urine 
after, 695. 
vaginal, 695. 
injection of bladder in, 668. 
instruments for, 668. 
lateral, 666. 
compared with supra-pu- 
bic, 692. 
incision of prostate in, 671. 
parts divided in, 666. 
surgical anatomy in, 666. 
median, 684. 
advantages and disadvan- 
tages of, 685. 
modifications of, 687. 
statistics of, 686. 
medio-bilateral, 689. 
medio-lateral, 687. 
methods of, compared, 692. 
mortality after, 682. 
age in, 682. 
comparative sex in, 696. 
general health in, 683. 
of recto-vesical, 690. 
Labia, abscess of, 717. 
adhesions of, 716. 
contusions of, 717. 
elephantiasis of, 720. 
epithelioma of, 721. 
diagnosis from chancre, 
721. 
follicular disease of, 719. 
gangrene of, 717. 
haeinatocele of, 717- 
hypertrophy of, 719. 
oedema of, 717. 
diagnosed from hydrocele, 
578. 
papilloma of, 721. 
varicose veins of, 720. 
diagnosis from hydrocele, 
578. 
during pregnancy, 720. 
warts upon, 721. 
wounds of, 716. 
Lacerated wounds of penis, 424. 
Laceration of cervix uteri, 762. 
of ligaments in dislocations, 
21. 
of perineum, 726. 
of urethra, 440. 
Lachrymation in spine injuries, 
856. 
Laparo-elytrotomy, 823. 
Laparotomy in extra-uterine 
pregnancy, 83L 
for myo-fibromata, statistics 
of, 772. 
ovaries removed by, 785. 
Larvngitis in Pott's disease, 
873. 
Laryngotomy in erysipelatous 
pharyngitis, 1008. 
in laryngeal erysipelas, 412. 
in retropharyngeal abscess, 
1010. 
Latent disease developed by 
masturbation, 605. 
Lateral curvature of spine, 860. 
Leeches in acute cystitis, 528. 
in acute prostatitis, 496. 
Leg, amputation of, 362. 
excision in continuity of 
bones of, 254. 
Leucorrhoea caused by elon- 
gated cervix uteri, 780. 
by polypi, 774. 
diagnosis from gonorrhoea, 
738. 
pruritus vulvas from, 724. 
Lever and traction forceps, 
Charriere's, 85. 
pessary, 754. 
Levis's forceps in circumcision, 
429. 
lever-tractor, 85. 
Ligaments, absorption of, caus- 
ing dislocations. 18. 
changes of, in spinal curva- 
ture, 867. 
in strumous arthritis, 159. 
elongation of, in spinal curva- 
ture, 863. 
laceration of, in dislocations, 
21. 
of ankle, 116. 
L. 1054 
INDEX TO VOLUME II. 
Lithotomy, mortality of vagi- 
nai, 695. 
season of year in, 683. 
size and weight of stone in, 
682. 
surgical skill in, 683. 
oblique incisions of prostate 
in, 674. 
office of staff-holder in, 670. 
orchitis after, 681. 
pelvic cellulitis after, 680. 
peritonitis after, 681. 
preparatory treatment for, 
665. 
prerectal, 689. 
prostatitis after, 680. 
pyaemia after, 681. 
recto-vesical, 690. 
rectum wounded in, 679. 
relapse after, 683. 
retention of urine after, 679. 
sexual defects after, 604, 681. 
sloughing after, 680. 
statistics of, 665,682, 686, 692. 
suitable cases for, 693. 
suppression of urine after, 
681. 
supra-pubic, 690. 
compared with lateral, 692. 
merits of, 692. 
urinary infiltration in, 691. 
test repeated before, 667. 
time of day for, 667. 
washing bladder after, 673. 
wound, healing of, 676. 
Lithotrite, fracture of, 661. 
varieties of, 652, 658. 
Lithotrity, 651. 
anaesthetics in, 654. 
cautions in, 656. 
compared with lithotomy, 662. 
complications in, 660. 
accidents to lithotrite, 661. 
atony, or paralysis, of blad- 
der, 660. 
impaction of fragments, 
661. 
perforation of bladder, 661. 
debris in, removed naturally, 
658. 
evacuators in, Bigelow's, 659. 
Dittel's, 659. 
Clover's, 658. 
Colin's, 659. 
objections to use of, 659. 
history of, 651. 
incision of meatus in, 654. 
in female, 694. 
instruments for, 652. 
management of debris in, 658. 
mortality after, 661. 
operation for, 654. 
preparatory treatment for, 
654. 
relapse after, 662. 
sequences of, 660. 
cystitis, 660. 
hemorrhage, 660. 
orchitis, 661. 
pyaemia, 661. 
traumatic or urethro-vesi- 
cal fever, 660. 
suppression of urine, 661. 
suitable cases for, 653, 693. 
time to be occupied in, 656. 
Local anaesthetics, 291. 
London paste, 989, 1007. 
Lordosis, 868. 
Lueifer-match necrosis, 951. 
Lumbar abscess, 872, 875. 
Luxations, 17. See Dislocationn. 
Lymphadenoma of testis, 593. 
Lymphatics in erysipelas, 404, 
407. 
purulent absorption by, 386. 
Lymph scrotum, 524. 
Maxilla, inferior, tumors of, 955. 
Maxilla, superior, 957. 
carcinoma of, 961. 
in antrum of, 962. 
diseases of antrum of, 957. 
enchondroma of, 963. 
excision of, 970. 
exostosis of, 964. 
fibroma of, 962. 
hare-lip involving, 902. 
hyperostosis of, 965. 
myelo-sarcoma of, 960. 
sarcoma of, 960. 
cystic, 961. 
tumors of, 960. 
osseous, 961. 
post-maxillary, 974. 
Maxillae, abscess of, 950. 
exploratory puncture in, 
950. 
treatment by trephining, 
950. 
anatomical relations of, 946. 
changed, in dentigerous cysts, 
938. 
excision of, 965. See Ejc- 
cisionn. 
necrosis of, 950. 
mercurial, 954. 
phosphor-, 951. 
syphilitic, 954. 
osteitis of, 949. 
treatment of, 949. 
periostitis of, 948. 
sequela? of, 949. 
treatment of, 949. 
phosphor-necrosis of, 951. 
pathology of, 953. 
repair after, 953. 
statistics of, 952. 
symptoms of, 952. 
treatment of, 953. 
Melanosis of testis, 591. 
Membranous stricture of ure- 
thra, 477. 
Meningitis of spinal cord, 846. 
Meningocele, 886. 
diagnosis of, 887. 
treatment of, 888. 
Menorrhagia from polypi, 774. 
Menses after oophorectomy, 792. 
retention of, 735. 
from polypi, 774. 
peritonitis after, 735. 
treatment for, 735. 
Mercurial poisoning, 1033. 
Mercurials in erysipelas, 410. 
Metacarpal bones, amputation 
of, 337. 
bone of thumb, dislocation of, 
82. 
Metacarpo-phalangeal amputa • 
tions, 335. 
joints, compound dislocation 
of, 28. 
Metacarpus, dislocation of, 82. 
excision of, 226. 
Metastatic abscess, 384. 
after traumatic fever, 389. 
in pyaemia, 387. 
Metatarsal amputations, 353. 
bones, dislocations of, 125. 
Metatarso-phalangeal amputa- 
tions, 352. 
Metatarsus, dislocations of, 125. 
Methylene, bichloride of, 289. 
Miasmatic origin of traumatic 
fever, 388. 
M. 
Macrostoma, 903. 
Malformations, amputation for, 
296. 
of bladder, 609. 
of head, from effusion, 885. 
of Ups, 889, 891, 897. 
of palate, 974. 
of tongue, 904. 
of urethra, female, 825. 
male, 450. 
of vagina, 732. 
Malignant degeneration of 
stump, 323. 
growths, amputation for, 294. 
stricture of oesophagus, 1019. 
Malpositions in coxalgia, 174. 
corrected, 176. 
tenotomy in, 162. 
Malum senile coxa?, 154. 
Mammary gland, inflamed in 
mumps, 997. 
Mania a potu after operations, 
278. 
Manipulation in dislocations, 
23. 
of hip, 94. 
of shoulder, 59. 
Marriage as a cure for irritable 
testis, 595. 
Massage after spine injuries, 
859. 
in neglected sprains, 133. 
in pseuijarthritis, 205. 
Masturbation after injuries to 
head, 605. 
atrophy of testis in, 597. 
developing latent disease, 605. 
incontinence of urine from, 
545. 
induced by phimosis, 427. 
irritable testis after, 595. 
relations of, to crime, 605. 
Maxilla, inferior, 946. 
anchylosis of, 946. 
carcinoma of, 957. 
changed by hypertrophied 
tongue, 906. 
cystic tumor of, 955. 
deformities of, 946. 
treatment of. 946. 
enchondroma of, 956. 
death from pressure by, 
956. 
excision of, 967. 
for dentigerous cysts, 939. 
for polycystic disease, 940. 
fibroma of, 955. 
recurring, 955. 
fracture, diagnosis from dis- 
location of, 36. 
osteoma of, 940. 
differential test for, 957. 
phosphor-necrosis of, 951. 
reproduction after, 953. 
polycystic disease of, 940. 
sarcoma of, 955. INDEX TO VOLUME IL 
1055 
Mobility, preternatural, in ar- 
thritis, 152. 
Monstrosity, congenital disloca- 
tions with, 33. 
Morbus coxarius, 162. 
Morgan's method in dislocation 
of hip, 96. 
Mortification, amputation in, 
296. 
from pressure, in erysipelas, 
411. 
from weight of scrotum, 523. 
in compound dislocations, 
with fracture, 30. 
of scrotum, 519. 
Morton's ward carriage, 275. 
Motion, passive, after disloca- 
tions of elbow, 73. 
Mouth, diseases of, 889. 
Movable bodies in joints, 127. 
after osteo-arthritis, 158. 
Muco-pus in hydronephrosis, 
904. 
Mucous membranes, erysipelas 
of, 406, 1008. 
patches after gonorrhoea, 739. 
Mulberry calculus, 637. 
Multilocular cysts, ovarian, 
793. 
Multiple injury, 38. 
Mumps, 997. 
orchitis after, 585. 
reflex anchylosis of jaw in, 
947. 
Muscles, atrophy of, in arthritis, 
200. 
biceps flexor cubiti, disloca- 
tion of tendon of, 67. 
changes of, in congenital dis- 
locations, 33. 
deltoid, paralysis of, in axil- 
lary dislocations, 53. 
digastric, spasm of, 38. 
effects of chloroform upon, 
287. 
fatty degeneration of, after 
dislocations, 22. 
laceration of, in dislocations, 
21. 54. 
old, 32, 64. 
latissimus dorsi, displacement 
of, 52. 
Muscular action, dislocations 
from, 19. 
relaxation, dislocations in, 19. 
resistance after dislocations, 
23. 
system in spinal curvature, 
861. 
weakness causing axillary 
dislocation, 54. 
Myalgia, spinal, 842. 
Myelitis of spinal cord, 846. 
Myoma of testis, 594. 
Myotomy in cleft palate, 977. 
in lateral curvature of spine, 
866. 
in stammering, 904. 
Myxomata of lip, 893. 
of vulva, 723. 
Nausea after ether, 286. 
Necrosis after amputations, 320. 
after compound dislocations, 
28. 
after periostitis of jaw, 949. 
amputation for, 295. 
in coxalgia, 185. 
in occipito-atloid arthritis, 
196. 
in struma, 162. 
of jaws, 950. 
from teeth, 924. 
of tooth, 927. 
phosphor-, 951. 
Needle for lacerated perineum, 
729. 
for vesico-vaginal fistula, 744. 
Nephritis, acute, 698. 
treatment of, 698. 
chronic, 699. 
albuminous urine in, 699. 
tendency to suppuration in, 
699. 
treatment of, 699. 
Nephrotomy, abdominal, 713. 
causes demanding, 713. 
in hydronephrosis, 705. 
in perinephritic abscess, 703. 
in renal tuberculosis, 710. 
lumbar, 713. 
Nerve-centres, changes of, in 
stump, 317. 
function of, impaired in spinal 
curvature, 863. 
lingual, division of, 913. 
relation of, to masturbation, 
605. 
Nerves, disposition of, in ampu- 
tations, 313. 
injury to, in dislocations, 21, 
32, 53, 65, 106. 
Nervous joint-disease, 203. 
Neuralgia after dislocation of 
coccyx, 88. 
diagnosis from Pott's disease, 
875. 
facial, from teeth, 924. 
in Pott's disease, 873. 
in stumps, 321. 
of bladder, 534. 
of pharynx, 1005. 
of testis, 595. 
of urethra, 475. 
Neuroses of bladder, 534. 
of joints, 203. 
of pharynx, 1003. 
Nitrate of silver poisoning, 
1033. 
Nitrite of amyl in chlorofonn- 
poisoning, 288. 
Nitrous oxide, 289. 
in extracting teeth, 933. 
modeof administering, 290. 
surgical uses of, 289. 
Nose, deformities of, 902. 
Nucleus of calculus, 635. 
Numbness in dislocations, 19, 
57. 
Odontoid process, fracture of, 
44. 
Odontomes, 937. 
(Edema in dislocations, 20. 
in renal cancer, 712. 
of penis, 424. 
of scrotum, 517. 
of vulva, 717. 
(Esophageal fbrceps, 1016. 
(Esophagismus, 1026. 
diagnosis of, 1026. 
treatment of, 1027. 
(Esophagotomy, 1028. 
circumstances requiring, 1028. 
externa], 1028. 
for stenosis, 1023. 
interna], 1029. 
results of, 1029. 
(Esophagus, 1014. 
abscess behind, 1018. 
tracheotomy in, 1019. 
carcinoma of, 1025. 
congenital imperfections of, 
1014. 
diverticula of, 1023. 
usual seat of, 1023. 
treatment of, 1024. 
fibromata of, 1025. 
fistula in, 1018. 
treatment of, 1018. 
foreign bodies in, 1014. 
instruments for extraction 
of, 1016. 
migration of, 1015. 
proper position of patient 
with, 1015. 
sulfocation from, 1014. 
paralysis of, diagnosis from 
stricture, 1027. 
parasitic growths of, 1025. 
polypus of, 1025. 
rupture of, during emesis, 
1017. 
sarcoma of, 1025. 
spasm of, 1026. 
stenosis of, 1019. 
auscultation in, 1020. 
diagnosis of, 1021. 
from paralysis of, 1027. 
dilatation above the seat of, 
1020. 
from cancer, 1019. 
from traumatism, 1019. 
prognosis in, 1021. 
symptoms of, 1020. 
treatment of, 1022. 
usual seat of, 1019. 
stricture of, 1019. 
varices of, 1024. 
wounds of, 1017. 
treatment of, 1018. 
Oidium albicans, 910. 
Olecranon, fracture of, compli- 
cating dislocations, 74. 
to reduce dislocation of 
elbow, 73. 
Oophorectomy, 785. 
by elytrotomy, 785. 
by laparotomy, 785. 
considerations deciding, 7S6. 
menses influenced by, 792. 
statistics of, 787. 
Operations, accidents during 
and after, 276. 
after-treatment of, 274. 
anaesthetics in, 272, 278. 
assistants required at, 271. 
conditions deciding, 268. 
0. 
N. 
Oakum as a drainage-tube, 192. 
Obturator dislocations, 98. 
Occipito-atloid and atlo-axoid 
joints, arthritis of, 195. 
Odontalgia, 929. 
conditions causing, 929. 
treatment by extraction, 931. 
Naevus, or angeiomata, of back, 
839. 
of gums, 922. 
of lip, 892. 1056 
INDEX TO VOLUME II. 
Operations, conditions influ- 
encing success of, 268. 
" decorative," or for conve- 
nience, 270. 
diet after, 274. 
dressing of wounds after, 273. 
removal of, 275. 
embolism after, 277. 
entrance of air into veins 
during, 277. 
exhaustion after, 276. 
transfusion of blood after, 
277. 
glazing of wounds after, 273. 
gouging, 192. 
hemorrhage in, control of, 
during, 273. 
recurrent, 277. 
secondary, 278. 
hour best suited for, 271. 
hysteroidal delirium after, 
278. 
mania a potu after, treatment 
of, 278. 
muscular spasm after, 279. 
personal cleanliness at, 272. 
preparations for, 271. 
of patient for, 268. 
proper use of sponge in, 272. 
retention of urine after, 279. 
soreness after, 276. 
syncope during, 273. 
table for, 272. 
tetanus after, 279. 
ventilation and temperature 
of apartments for, 271. 
Ophthalmia, gonorrhoeal, 474. 
Opium-poisoning. 1033. 
Orbit preserved in excision of 
upper jaw, 972. 
Orchitis, acute, 584. 
after gonorrhoea, 469. 
after lithotomy, 681. 
after lithotrity, 661. 
after mumps, 585. 
diagnosis of, 584. 
pathology of, 584. 
symptoms of, 584. 
treatment of gouty, 585. 
of rheumatic, 585. 
chronic, 585.' 
morbid anatomy in, 586. 
treatment of, 586. 
strumous, 587. 
diagnosis from syphilitic, 
589. 
morbid anatomy in, 588. 
symptoms of, 587. 
terminations of, 588. 
treatment of, 589. 
syphilitic, 586, 
diagnosis of, 587. 
from tubercular, 589. 
morbid anatomy of, 586. 
treatment of, 587. 
tubercular, 587. 
Organic stricture of oesophagus, 
1019. 
of urethra, 478. 
Os calcis, dislocations of, 124. 
excision of, 257. 
Os cuboides, dislocation of, 125. 
excision of, 260. 
Os cuneiforme, dislocation of, 
82. 
excision of, 260. 
Os magnum, dislocation of, 81. 
Os pisiforme, dislocation of, 82. 
Osscaphoides, dislocation of, 125. 
excision of, 260. 
Os semilunare, dislocation of, 
81. 
Os unciforme, dislocation of, 82. 
Osseous anchylosis, 140. 
Osteitis, 158. 
after periostitis of jaw, 949. 
in ankle disease, 191. 
in white swelling, 187. 
of jaw, 949. 
Osteo-arthritis, 154. 
Osteo-epiphysitis in coxalgia, 
165. 
Osteoma, dentigerous, 940. 
of lower jaw, 956. 
of upper jaw, 964. 
Osteomyelitis after amputation, 
320. 
amputation for, 295. 
reamputation for, 326. 
Osteotomy, subcutaneous, 184. 
in old dislocations, 32, 106. 
in osseous anchylosis, 145, 
183. 
Ovarian tumors, 793. 
carcinomatous, 814. 
causes of, 794. 
classification of, 793. 
cystic, 793. 
contents of, 793. 
diagnosis of, 795. 
exploratory incision in, 
798. 
from ascites, 796. 
from colloid, encephaloid, 
and papillomatous tu- 
mors, 796. 
from extra-uterine preg- 
nancy, 833. 
from fi bro-cysts of uterus, 
795. 
from hydronephrosis, 
704. 
from myo-fibromata, 768. 
from pregnancy, 796. 
from renal cancer, 712. 
of adhesions, 799. 
of length of pedicle, 799. 
of variety, 798. 
tapping in, 797. 
duration of, 799. 
enchondromatous, 814. 
evacuated by ulceration, 
799. 
fibromatous, 813. 
prognosis in, 800. 
sarcomatous, 814. 
symptoms of, 795. 
treatment by drainage, 802. 
by incision, 802. 
by injection, 802. 
by ovariotomy, 802. 
by partial excision, 802. 
by tapping through ab- 
dominal walls, 800. 
through vagina, 801. 
Ovaries, abscess of, 783. 
symptoms of, 784. 
treatment of, 784. 
atrophy of, 783. 
dislocation of, 784. 
diagnosis from hernia, 784. 
treatment of, 784. 
hypertrophy of, 783. 
symptoms of, 783. 
treatment of, 783. 
inflammation of, 782. 
Ovaries, tubercle of, 814. 
tumors of, 793. 
Ovariotomy, 802. 
after-treatment of, 810. 
antiseptics in, 810. 
assistants for, 806. 
diet after, 810. 
drainage-tube in, 810. 
history of, 802. 
instruments for, 804. 
operation of, 806. 
abdominal incision in, 807. 
closing of wound in, 809. 
emptying the sac in, 807. 
incision of peritoneum in, 
807. 
securing the pedicle in, 808. 
by cautery, 808. 
by clamp, 808. 
by 6craseur, 808. 
by ligature, 808. 
treatment of adhesions in, 
808. 
place for, 803. 
preparatory measures for, 
803. 
proper period for operation 
of, 803. 
sequelae, 810. 
hemorrhage, 810. 
peritonitis, 811. 
septajmia, 811. 
shock, 810. 
statistics of, 811. 
Ovaritis, 782. 
after gonorrhoea, 739. 
sequelae of, 783. 
symptoms of, 782. 
treatment of, 782. 
Oxalate of lime calculus, 637. 
in urine, 625. 
Oxalic acid poisoning, 1034. 
Oxaluria, 625. 
causing impotence, 602. 
incontinence of urine in, 544. 
treatment of, 626. 
urethritis from, 459. 
p. 
Pachydermia lymphangiectat- 
ica, 525. 
Pain as a depressant, 274. 
death from, 274. 
in dislocations, 19. 
in spine injuries, 855. 
Painful cicatrix, 417. 
Palate, cleft, 974. 
age for operating upon, 97a 
hard, abscess of, 978. 
cleft in, 979. 
treatment by urano- 
plasty, 979. 
mechanically, 981. 
gangrene of, 979. 
hypertrophy of, 978. 
perforations of, 981. 
vascular tumors of, 979. 
soft, abscess of, 983. 
adetwma of, 983. 
carcinoma of, 984. 
arrest of hemorrhage 
from, 984. 
cysts of, 984. 
fibroma of, 985. 
guinmata of, 983. 
inflammation of, 983. INDEX TO VOLUME II. 
1057 
Palate, soft, ulceration of, 983. 
wounds of, 983. 
Palpitation of heart in spinal 
curvature, 863. 
Papillary disease of tongue, 908. 
Papilloma of bladder, 547. 
of gums, 922. 
of labia, 721. 
of lip, 893. 
of tongue, 910. 
of urethra, 459. 
of vagina, 737. 
Paralysis after lightning- 
stroke, 423. 
after spinal lesions, 845, 846, 
854. 
atrophy of testis in, 597. 
causing dislocations, 19, 54. 
facial, after excision of pa- 
rotid, 1001. 
from phimosis, 427. 
in oecipito-atloid arthritis, 
196. 
in osteo-arthritis, 155. 
in Pott's disease, 874. 
in vertebral dislocations, 43, 
45. 
of bladder, 540. 
with hypertrophied pros- 
tate, 502. 
of deltoid muscle in axillary 
dislocations, 53. 
causing axillary disloca- 
tion, 54. 
of oesophagus, 1027. 
of pharynx, 1004. 
vaso motor, in spine injuries, 
856. 
Paraphimosis, 430. 
treatment of, by incision, 431. 
by manipulation, 430. 
Parasites in bladder, 538. 
in kidney, 709. 
pruritus vulvae from, 724. 
upon gen.tals, 5 I 6. 
Parasitic growths of gullet, 1025. 
of mouth, 910. 
Paresis after dislocations, 21. 
old, 32. 
after sprain of spine, 841. 
of neck of bladder, 542. 
Parotid gland, 997. 
abscess of, 997. 
evil effects from, 997. 
method of incising, 997. 
calculus in, 998. 
extirpation of, 1001. 
facial paralysis after, 1001. 
ligation of carotid in, 1001. 
inflammation of, 997. 
nervous enlargement of, 998. 
tumors of, 998. 
ligation of carotid for, 1002. 
over, 999. 
destruction of parotid 
by, 1000. 
fibromatous, 1000. 
lymphomatous, 999. 
Parotitis, 997. 
inflammation of mammary 
gland after, 997. 
orchitis after, 997. 
treatment of, 997. 
Parturition, difficult, from foetal 
hydronephrosis, 703. 
dislocation of coccyx during, 
88. 
of os magnum during, 81. 
Parturition, dislocation upon 
child during, 33. 
pelvic cellulitis after, 818. 
prevented by calculus, 648. 
vesico-vaginal fistula caused 
by protracted, 742. 
caused by use of instru- 
ments in, 742. 
Passive motion in ankle dis- 
ease, 193. 
in dislocations, 28, 62. 
compound, 28. 
of hip, 98. 
of knee, 113, 114. 
of wrist, 79. 
in excisions, 212. 
of wrist,. 222. 
synovitis, 140. 
Patella, dislocations of, 107. 
congenital, 111. 
excision of, 253. 
reflex, in nerve-lesions, 848. 
removal of, in amputations 
at knee, 366. 
in excision of knee, 235. 
Pelvic cellulitis, 817. 
after lithotomy, 680. 
Pelvis, angle of, in posterior 
spinal curvature, 867. 
dislocation of bones of, 87. 
distorted, lithotomy in, 675. 
elevation of, in coxalgia, 164. 
malformations of, delaying 
extraction, in lithotomy, 
675. 
Penetrating wound of chest, 66. 
Penis, ablation of, for cancer, 
434. 
treatment of stump after, 
433. 
absence of, causing impo- 
tence, 600. 
calcification of, 437. 
cancer of, 432. 
corpus spongiosum of, short, 
451. 
wounds of, 439. 
curvature of, 437. 
in hypospadias, 451. 
diminutive, causing impo- 
tence, 600. 
diseases of integument of, 
424. 
eczema of, 426. 
embolism of, after gonor- 
rhoea, 469. 
epithelioma of, 432. 
erections of, after operations 
upon. 452. 
after wounds of, 440. 
fracture of, 436. 
gangrene of, 435. 
idiopathic, 436. 
herpes of, 425. 
hypertrophy of prepuce of, 
426. 
inflammation of, 434. 
of glans, 425. 
of mucous surface of pre- 
puce of, 425. 
luxation of, 437. 
oedema of, 424. 
preputial concretions of, 425. 
dysuria from, 425. 
scirrhus of, 432. 
urinal for stump of, 434. 
warts on, 438. 
wounds of body of, 438. 
Penis, wounds of integument of, 
424. 
of urethra of, 439, 440. 
Penny impacted in oesophagus, 
1014. 
Pericoecal abscess in Pott's dis- 
ease, 875. 
Peri-metritis, 817. 
Perineal artery, transverse, li- 
gation of, after lithotomy, 
677. 
band in dislocations, 26. 
incision in lacerated urethra, 
442. 
section, 492, 493. 
in urethroplasty, 449. 
urethrotomy, 493. 
Perinephritic abscess, 701. 
diagnosis of, 702. 
in Pott's disease, 875. 
nephrotomy for, 703, 713. 
symptoms of, 702. 
treatment of, 703. 
Perineum, lacerations of, 726. 
after-treatment of, 732. 
removal of sutures in, 
732. 
causes of, 726. 
changes following, 727. 
evil results of, 727. 
involving recto-vaginal 
septum, 727. 
modes of operating for, 728. 
operation, closure of wound 
in, 731. 
instruments for, 729. 
introduction of sutures 
in, 730. 
preparation for, 728. 
primary, 728. 
secondary, 728. 
prolapsus uteri in, 727. 
time to operate for, 728. 
varieties of, 727. 
puncture of bladder through, 
513. 
Periosteal elevator, 209. 
flaps in amputation, 302. 
Periosteum preserved in excis- 
ion, 186. 
reproduction of bone from, 
208. 
conditions favoring, 208. 
Periostitis of jaw, 948. 
Peritonitis after gonorrhoea, 
740. 
after lithotomy, 681. 
after ovariotomy, 811. 
after peri-uterine haemato- 
cele, 817. 
in burns, 415. 
puerperal, during erysipelas, 
402. 
with pelvic cellulitis, 819. 
Peri-uterine haematocele, 815. 
Peri-uteritis, 817. 
Pernio, 420. 
action of cold in producing, 
421. 
causes predisposing to, 420. 
degrees of, 420. 
inflammation with vesication 
after, 421. 
influence of moisture in, 420. 
mortification after, 421. 
treatment of, 421. 
ulceration after, 421. 
Peroneo-tibial dislocations, 120. 
vol. ii.-67 1058 
INDEX TO VOLUME II. 
Pessary, Campbell's spring 
stem, 761. 
cup, 755. 
Hodge's lever, 754. 
in procidentia uteri, 754. 
in treatment of malpositions 
of uterus, 755. 
Meigs's ring, 754. 
Thomas's anteversion, 759. 
vesico-vaginal fistula from, 
742. 
Phagedaenic chancre causing in- 
flammation of penis, 434. 
Phalanges, amputation of, 333, 
352. 
dislocations of, 28, 87. 
excision of, 225. 
webbed, pre vention of, after 
burns, 419. 
Pharyngitis, acute, 1005. 
atrophic, 1006. 
diphtheritic, 1007. 
erysipelatous, 1008. 
laryngotomy in, 1008. 
follicular, 1006. 
exudative, 1006. 
hypertrophic, 1006. 
treatment of, 1007. 
syphilitic, 1008. 
Pharyngo-oesophageal diverti- 
cula, 1023. 
Pharynx, abscess behind, 1008. 
affections of, 1002. 
anaesthesia of, 1003. 
chorea of, 1004. 
cicatricial stenosis of, 1012. 
congenital defects of, 1003. 
dilatation of, 1013. 
diverticula in, 1013. 
erosion of, by caustics, 1010. 
fistula in, 1011. 
foreign bodies in, 1012. 
hyperaesthesia of, 1003. 
inflammation of, 1005. 
nervous dysphagia of, 1004. 
neuralgia of, 1005. 
paralysis of, 1004. 
perverted sensation in, 1004. 
scalds of, 1010. 
tracheotomy in, 1010. 
spasm of, 1003. 
stenosis of, 1012. 
tenaceous mucus in, during 
anaesthesia, 285. 
tumors of, 1013. 
wounds of, 1010. 
hemorrhage in, 1011. 
treatment of, 1010. 
use of sutures in, 1011. 
Phimosis, 426. 
acquired, 429. 
adhesions in, 428. 
circumcision for, 427. 
arrest of hemorrhage in, 
428. 
congenital, 426. 
diseases caused by, 426. 
Levis's forceps in, 429. 
pyelitis after, 699. 
treatment of, 427, 430. 
by dilatation, 427. 
by incision, 429. 
Phlebitis, 384. 
diagnosis of, from erysipelas, 
408. 
Phlebotomy, 265. 
Phlegmon, 397. 
Phlegmonous erysipelas, 405. 
Phosphate of lime calculus, 638. 
Phosphatic urine, 627. 
Phosphor-necrosis, 951. 
Phosphorus-poisoning, 1033. 
Phrenic nerve, pressure upon, 
43. 
Placenta, treatment of, in extra- 
uterine pregnancy, 834. 
Plaster of Paris in ankle dis- 
ease, 191. 
in dislocations, compound, 
29. 
of foot, 117. 
of thumb, 86. 
in elbow disease, 201. 
in excision of ankle, 242. 
of elbow, 218. 
of knee, 235. 
in Pott's disease, 878. 
in sprain of spine, 841. 
in white swelling, 188. 
Plastic operations for cicatrices, 
419. 
upon lips, 895. 
Pleurodynia in spinal curva- 
ture, 869. 
Pleuro-pneumonia in burns, 
415. 
Pneumonia, diagnosis of, from 
traumatic fever, 394. 
Poisoned wounds of lip, 892. 
Poisoning by arsenic, 1033. 
by atropia, 1034. 
by corrosive sublimate, 1033. 
by mineral acids, 1033. 
by nitrate of silver, 1033. 
by opium, 1033. 
by oxalic acid, 1034. 
by phosphorus, 1033. 
by strychnia, 1034. 
Poisons in stomach, treatment 
of mineral, 1033. 
of vegetable, 1033. 
use of pump in, 1034. 
Polypus of bladder, 547. 
of oesophagus, 1025. 
of tongue, 912. 
of urethra, 459. 
uterine, 773. 
adenoid, 774. 
arrest of hemorrhage from, 
777. 
fibro-myomatous, 773. 
mucous, 773. 
symptoms of, 774. 
treatment by (icrasement, 
775. 
by excision, 775. 
by ligation, 776. 
by torsion, 774. 
varieties of, 773. 
Popliteal vein, ligation of, after 
amputations, 367. 
Porro operation, 822. 
Position for anchylosis, over- 
looked, 142. 
Posthitis, 425, 462. 
in gonorrhoea, 467. 
Pott's disease of spine, 869. 
fracture, with dislocation of 
ankle, 117. 
Poultice, soda, for anthrax, 400. 
Pregnancy, diagnosis of, from 
ovarian tumors, 796. 
extra-uterine, 829. 
causes of, 829. 
considerations deciding 
operation in, 835. 
Pregnancy, extra-uterine, de- 
cidua in, 830. 
diagnosis of, 832. 
from pelvic cellulitis, 832. 
from haematocele, 833. 
from uterine tumors, 833. 
from ovarian tumors, 833. 
frequency of, 829. 
progress and terminations 
of, 830. 
rupture of sac in, 835. 
symptoms of, 831. 
treatment of, by destroying 
the ovum, 833. 
by laparotomy, 834. 
by removal per vaginam, 
• 834. 
of placenta in, 834. 
varieties of, 830. 
pruritus vulvas in, 724. 
varicose labia during, 720. 
Prepuce, absence of fraenum of, 
432. 
circumcision of, 427. 
eczema of, 426. 
epithelioma of, 432. 
herpes of, 425. 
hypertrophy of, 426. 
inflammation of, 425. 
paraphimosis of, 430. 
phimosis of, 426. 
short fraenum of, 431. 
Preputial concretions, 425. 
deformities, incontinence of 
urine from, 545. 
Pressure, arrest of hemorrhage 
by, 273. 
Preternatural mobility in ankle- 
joint disease, 190. 
Priapism, 437. 
after operations upon penis, 
452. 
after wounds of penis, 440. 
during gonorrhoea, 465. 
from calculus, 642. 
from phimosis, 427. 
in spine injuries, 856. 
treatment of, 438. 
Primary amputations, 296. 
Probang, sponge, 1017. 
Procidentia uteri, causes of, 753. 
diagnosis of, from prolapsus 
vaginae, 736. 
symptoms of, 753. 
treatment of, 754. 
Prolapsus recti from hypertro- 
phied prostate, 502. 
from urethral stricture, 479. 
in lacerated perineum, 727. 
uteri, 753. 
in lacerated perineum, 727. 
vaginae, 736. 
Prostate, 494. 
abscess of, 497. 
disorganization after, 497. 
external to, 498. 
treatment of, 497. 
anatomical relations of, 494. 
as an analogue of uterus, 501. 
cancer of, 506. 
cheesy deposits in, 506. 
cysts of, 506. 
hypertrophy of, 499. 
age in, 499. 
catheterization in, 504. 
causing calculus, 632. 
centric, 500. 
cystitis in, 502. INDEX TO VOLUME II. 
1059 
Prostate, hypertrophy of, diag- 
nosis of, 502. 
dilatation of ureter from, 
503. 
eccentric, 500. 
frequency of, 500. 
incontinence of urine in, 
544. 
inflammation of, 495. 
pathology of, 500. 
pyelitis after, 699. 
retention of urine from, 
509. 
sequelae of, 502. 
symptoms of, 501. 
treatment, of, 503. 
vesical paralysis in, 502. 
incision of, in lithotomy, 
671. 
laceration of, in lithotomy, 
673. 
oblique incisions in, for large 
stones, 674. 
tumors of, 501. 
complicating lithotomy, 
675. 
Prostatic calculus, 505. 
hemorrhage, 506. 
Prostatitis, acute, 495. 
after lithotomy, 680. 
diagnosis from cystitis, 495, 
527. 
from stone, 495. 
in gonorrhoea, 468. 
pathology of, 495. 
symptoms of, 495. 
treatment of, 496. 
chronic, 496. 
treatment of, 496. 
Prostatorrhoea, 498. 
signs of, 498. 
treatment of, 499. 
Pruritus scroti, 515. 
vulvas, 724. 
treatment of, 724. 
Pseudarthritis, 203. 
causes of, 204. 
diagnosis, anaesthetics in, 
205. 
cautery in, 205. 
from arthritis, 204. 
from eoxalgia, 205. 
from knee-joint disease, 
205. 
frequency of, 203. 
overlooked, 203. 
symptoms of, 204. 
treatment by massage, 205. 
psychologically, 205. 
Pseudarthrosis after fracture in 
unreduced luxations, 66. 
after true anchylosis, 144. 
in eoxalgia, 170. 
in dislocations, congenital, 
33. 
old, 32, 66. 
in vicious anchylosis of elbow, 
216. 
Pseudo-impotence, 602. 
Psoas abscess, 872. 
diagnosis from eoxalgia, 
' 172. 
from perinephritis, 702. 
Psoriasis linguae, 908. 
Ptyalism, anchylosis after, 947. 
Pubic dislocations, 100. 
symphysis, absence of, in 
epispadias, 452. 
Pudendal haematocele, or throm- 
bus, 717. 
Pulleys in dislocations of hip, 
96. 
Puncture of bladder, infra- 
pubic, 514. 
inter-pubic, 514. 
through perineum, 513. 
of ovarian cysts, 800. 
use of, 264. 
Pupils in spine injuries, 856. 
Purgatives in erysipelas, 410. 
Pus, effects of, in blood, 387. 
entrance of, into vascular 
system, 385. 
formation of, in erysipelas, 
405. 
in urine, 619. 
Pyaemia, 385. 
after lithotomy, 681. 
after lithotrity, 661. 
in compound dislocations, 
28. 
in pelvic cellulitis, 818. 
in wounds of joints, 136. 
metastatic abscess in, 387. 
morbid anatomy of, 389. 
pyelitis after, 699. 
statistics of, at Guy's Hos- 
pital, 395. 
at Pennsylvania Hospital, 
395. 
symptoms of, 391. 
temperature chart of, 392. 
treatment of, 395. 
Pyelitis, 699. 
causes of, 699. 
diagnosis from perinephritis, 
702. 
from renal tuberculosis, 
710. 
prognosis in, 700. 
suppuration in, 701. 
symptoms of, 700. 
treatment of, 700. 
Pyelonephritis, diagnosis from 
renal tuberculosis, 710. 
Pyonephritis, diagnosis from 
hydronephrosis, 705. 
Pyonephrosis, 701. 
Recto-vesical fistula, 536. 
after lithotomy, 679. 
lithotomy, 690. 
Recurring fibroma of lower jaw, 
955. 
Redness after frost-bite, 420. 
Renal calculus, 705. 
carcinoma, 710. 
colic, 707. 
symptoms of, 707. 
treatment of, 707. 
cysts, 708. 
contents of, 708. 
diagnosis from hydrone- 
phrosis, 704. 
hmmaturia, 708. 
parasites, 709. 
symptoms of, 709. 
treatment of, 709. 
tuberculosis, 710. 
Reparation after excisions, 208. 
Resection of joints and bones, 
206. See Excision. 
Respiration, artificial, in chloro- 
form-poisoning, 288. 
impaired, in Pott's disease, 
873. 
Respiratory anaesthesia, 290. 
Retention of urine, 507. See 
Urin e. 
Retractor in amputations, 301, 
364. 
Retro-oesophageal abscess, 1018. 
Retropharyngeal abscess, 1008. 
Retroversion of uterus, 755. 
forcing adhesions in, 757. 
genu-pectoral position in, 
757. 
signs of, 756. 
treatment of, 756. 
Rheumatism, diagnosis from 
eoxalgia, 173. 
from gonorrhoeal, 475. 
from Pott's disease, 875. 
from spine injury, 858. 
from traumatic fever, 395. 
gonorrhoeal, 474. 
simulating eoxalgia, 163. 
Rheumatismus deformans, 154. 
Rheumatoid arthritis, 154. 
anchylosis in, 947. 
Rhigolene, 292. 
Ribs and their cartilages, ex- 
cision of, 227. 
dislocation of, 38. 
position of, in cyphosis, 867. 
Rigors after urethral operations, 
444. 
Rope windlass, Gilbert's, 25. 
Round ligament, hydrocele' of, 
814. 
Round-shouldered, 867. 
Rupture of axillary artery in 
reducing old dislocations, 
64. 
of oesophagus during emesis, 
1017. 
of perineum, 726. 
of uterus, 836. 
Q. 
Quinia in hectic fever, 396. 
in urethral chills, 445. 
Quinsy, 985. 
diagnosis from pharyngeal 
erysipelas, 408. 
R. 
Rachitis, causing spinal curva- 
ture, 862, 867, 868. 
complicating lithotomy, 675. 
Radio-humeral dislocation, 68. 
Radio-ulnar dislocation, 77. 
Radius and ulna, dislocation of, 
70. 
excision of, 252. 
Ranula, 993. 
Rectal examination in eoxalgia, 
184. 
in luxations of hip, 94. 
fissure, cystitis from, 828. 
Rectocele, diagnosis from pro- 
lapsus vaginae, 736. 
8. 
Saccharine urine, 622. 
Sacculated bladder complicat- 
ing calculus, 645. 
Sacro-iliac arthritis, 196. 
diagnosis from coxalgia, 172, 1060 
INDEX TO VOLUME II. 
Sacro-iliac arthritis in spinal 
curvature, 862. 
Salivary calculus, 996, 998. 
fistula, 998. 
glands, diseases of, 993. 
Salivation, treatment of, 920. 
Salpingitis after gonorrhoea, 
739. 
Sarcocele, diagnosis from hydro- 
cele, 573. 
syphilitic, 586. 
Sarcoma of back, 839. 
of bladder, 549. 
of gullet, 1025. 
of lower jaw, 955. 
of ovary, 814. 
of testis, 592. 
of upper jaw, 960. 
of uterus, 779. 
Saw. Adams's, 145. 
Butcher's, 210. 
chain, 210. 
Sayre's apparatus for ankle dis- 
ease, 193. 
for coxalgia, 181. 
for knee disease, 188. 
for white swelling, 188, 
cuirass, 230. 
Scalds, 412. See Burns. 
of pharynx, 1010. 
Scales, furfuraceous, after ery- 
sipelas, 405. 
Scaphoid bone, dislocation of, 
125. 
excision of, 260. 
Scapula, dislocation of, 50. 
excision of, 248. 
Scars, 416, 419. 
Sciatica, diagnosis from sacro- 
iliac arthritis, 198. 
Sciatic nerve injured in dislo- 
cations, 106. 
Scrofulous arthritis, 154-203. 
theories concerning, 150. 
Scrotal calculi, 520. 
Scrotum, 514. 
adipose tumors of, 520. 
bifid, in hypospadias, 451. 
contusions of, 515. 
cystic tumor of, 519. 
eczema of, 515. 
elephantiasis of, 521. 
emphysema of, 517. 
enchondroma of, 520. 
epithelioma of, 525. 
extravasation of urine into, 
515. 
fibrous tumor of, 520. 
inflammation of, 518. 
diagnosis from oedema of, 
518. 
treatment of, 518. 
lymph, 524. 
mortification of, 519. 
oedema of, 517. 
treatment of, 517. 
pneumatocele of, 517. 
position of, in hydrocele, 
572. 
prurigo of, 515. 
redundancy of, 519. 
tumors of, 519. 
varicose veins of, 516. 
wounds of, 514. 
testicle in, 515. 
Scultetus bandage, 30. 
Sebaceous tumors of back, 839. 
of vulvae, 722. 
Secondary abscesses in pyaemia, 
389. 
hemorrhage, 278. 
after amputations, 320. 
period for amputation, 297. 
Sediments in urine, 623. 
Self-retaining catheter, 744. 
Semilunar bone, dislocation of, 
81. 
Seminal emissions in chronic 
prostatitis, 496. 
irritable te?tis after, 595. 
Senile hypertrophy of prostate, 
499. 
posterior curvature of spine, 
867. 
Sensitive cicatrix, 417. 
stump, 321. 
Septannia after ovariotomy, 811. 
Septicaemia, 385. 
Septicaemia theory of traumatic 
fever, 389. 
Serres-fines, arrest of hemor- 
rhage by, 273. 
Serum in joints after inflam- 
mation, 138, 139. 
Seton in ankle disease, 192. 
in infantile hydrocele, 576. 
in wrist and carpal disease, 
203. 
Sex in calculus, 631. 
in carcinoma of tongue, 
912. 
Sexual defects after lithotomy, 
681. 
Shock, 376. 
after burns, 414, 417. 
after ovariotomy, 810. 
anaesthetics in, 283. 
causes of, 378. 
conditions influencing the in- 
tensity of, 379. 
death from, 378. 
heart-spasm in, 377. 
delirium after nervous, 377. 
traumatic, 377. 
embolism during, 378. 
from passage of calculi, 378. 
from perforation of viscera, 
378. 
from strangulated bowel, 379. 
hysterical phenomena after, 
377. 
jaundice after, 378. 
modes of death in, 377, 381. 
nature of, 380. 
operations during, 383. 
post-mortem appearances 
after, 381. 
prognosis in, 381. 
pulse-tracings in, 376. 
secondary, 378. 
or remote effects of, 380. 
symptoms of, 376. 
of reaction from, 377. 
treatment of, 381. 
Shoe, high-soled, in ankle dis- 
ease, 191. 
in coxalgia, 175. 
in white swelling, 188. 
Shortening in dislocations, 20, 
57. 
probability of, after excision, 
209. 
Shot sutures in vesico-vaginal 
fistula, 746. 
Shoulder, amputations above, 
350. 
Shoulder, amputations at, 346. 
dislocation of, 46. 
compound, 28. 
excision of, 212. 
Silieious concretions, 640. 
Simple dislocation, 18. 
surgical fever, diagnosis from 
pyaemia, 394. 
traumatic infective fever, 384. 
Sinuses after pelvic abscess, 820. 
in ankle disease, 191. 
in arthritis, 132. 
in coxalgia, 167, 178. 
in struma, 159. 
Skin, callous, 413. 
post-mortem appearance of, 
after erysipelas, 407. 
vicarious function of, in kid- 
ney disease, 698. 
Skin-grafting in burns, 419. 
Sloughing after lithotomy, 680. 
in erysipelas, 405. 
ulcer of gums, 920. 
Smith's lithotomy apparatus, 
672. 
Soft palate, cleft in, 974. 
parts, laceration of, in com- 
pound luxations, 29. 
Sounding for stone, 642. 
sources of fallacy in, 644. 
Sounds, lithotomy, 642. 
Spanish windlass, 97. 
Spasm, muscular, after opera- 
tions, 279. 
in arthritis, 151. 
in spine injuries, 855. 
of digastric muscle, 38. 
of oesophagus, 1026. 
of stump, 318. 
of urethra, 476. 
Spasmodic retraction of sper- 
matic cord, 558. 
retention of urine, 511. 
stricture of oesophagus, 1019. 
of urethra, 476. 
Spaying of women, 785. 
Specific warts on penis, 438. 
on vulva, 721. 
Speculum, Sims's duck-bill, 
744. 
vaginal, 751. 
Speech after removal of tongue, 
919. 
Spermatic cord, 557. 
carcinoma of, 558. 
fatty tumors of, 558. 
confounded with hernia, 
558. 
hoematocele of, 561. 
hydrocele of, 559. 
inflammation of, 557. 
rupture of vas deferens of, 
557. 
spasmodic retraction of, 
558. 
syphilitic enlargement of, 
559. 
varicocele of, 562. 
wounds of, 557. 
Spermatorrhoea. 604. 
cauterization in, 608. 
diagnosis from prostator- 
rhoea, 499. 
symptoms of, 605. 
treatment of, 606. 
Spermatozoa in fluid of en- 
cysted hydrocele, 560, 57 1. 
in urine, 621. INDEX TO VOLUME If. 
1061 
Spermatozoa, sterility from ab- 
sence of, 603. 
Spina bifida, 851. 
Spinal abscesses. 872, 881. 
column, congenital defects of, 
851. 
mechanism of. 848. 
sprains of, 849. 
cord, anatomical relations of, 
842. 
compression of, 845. 
from blood, 845. 
from lymph, serum, or 
pus, 846. 
paralysis after, 846. 
concussion of. 842. 
from direct force, 843. 
from indirect force. 843. 
injury to, in vertebral dis- 
locations, 42. 
meningitis of, 846. 
in Pott's disease, 874. 
myelitis of, 846. 
tumors of, 848. 
value and significance of 
symptoms after injuries 
of, 847. 
wounds of, 844, 846. 
injuries, 848. 
blood-changes after, 857. 
cerebral symptoms after, 
857. 
deglutition after, 856. 
diagnosis from cerebral con- 
cussion, 858. 
from hysteria, 857. 
from rheumatism, 858. 
dyspnoea after, 856 
effects upon nutrition after, 
857. 
elevation of temperature 
after. 855. 
general phenomena follow- 
ing, 854. 
hypersesthesia after, 855. 
lachrymation after, 856. 
muscular spasms after, 855. 
pain after, 855. 
paralysis after, 854. 
priapism after, 856. 
prognosis in, 858. 
strabismus after, 856. 
treatment of, 858. 
variations of circulation 
after, 856. 
myalgia, 842. 
region, anatomy of, with re- 
lation to abscesses, 837. 
Spine, anatomical peculiarities 
of, 859. 
arching of, in coxalgia, 163. 
curvatures of. 859. 
anterior, 868. 
pathological changes in, 
868. 
symptoms of, 868. 
treatment of, 869. 
causes of, 860. 
lateral, 860. 
causes of, 861. 
structural alterations in, 
863. 
symptoms of, 862. 
treatment of, by appa- 
ratus, 865. 
by drill exercise, 864. 
posterior, 866. 
adolescent, 867. 
Spine, curvatures of. posterior, 
infantile, 866. 
pathological changes in, 
867. 
senile, 867. 
symptoms of, 867. 
treatment of, 867. 
posterior angular. 869. 
abscesses in, 872, 881. 
causes of, 870. 
complications, abscesses 
as, 881. 
eoxalgia as, 884. 
diagnosis from abscess, 
875. 
from aneurism, 875. 
from coxalgia. 172. 
from empyema, 876. 
from hysteria, 876. 
from kidney disease, 
875. 
from neuralgia, 875. 
from rheumatism, 875. 
from sacro-iliac arthri ■ 
tis, 198. 
from superficial caries, 
876. 
frequency of, 870. 
incontinence of urine in, 
544. 
laryngeal cough in. 873. 
movements impaired in, 
873. 
paralysis in, 874. 
prognosis in, 876. 
repair in. 877. 
structural alterations in, 
871. 
symptoms of, 872. 
treatment, 877. 
by leather support 880. 
by plaster bandage, 
878. 
of complications, 883. 
dislocations of, 40. 
injuries of, 848. 
osteo-arthritis of, 155. 
sprains of, 840. 
Splint, angular, 73, 119. 
.Ashhurst's, 236. 
Bond's, 77, 79. 
lateral, 116. 
McIntyre's, 30. 
obtuse-angled, 69, 169. 
of binders' board, 86. 
palmar, 28, 81, 222, 225. 
Packard's, 29, 236. 
Price's, 236. 
right-angled, 69. 
steel, in coxalgia, 175. 
straight, 77, 80. 
walking, in eoxalgia, 175. 
Sponge, use of, in operations, 
272. 
tents of, in myo-fibromata of 
uterus, 768. 
Spontaneous dislocation of clav- 
icle, 199. 
Sprains, 131. 
articular disease after, 131. 
changes after badly-treated 
or neglected. 133. 
diagnosis of, 21, 131. 
ligaments lacerated in, 131. 
of spine, 840, 849. 
diagnosis of, 841. 
haematuria after, 841. 
treatment of, 841. 
Sprains, treatment of, 131, 133. 
Spray apparatus, 934. 
Stammering, myotomy for, 904. 
of bladder. 511. 
Staphylorraphy, 975. 
after-treatment of, 978. 
complications in, 978. 
instruments for, 976. 
myotomy in, 977. 
tenotomy in, 975. 
Stenosis of oesophagus, 1019. 
of vagina, 733. 
Sterility, 603. 
after epididymitis, 583. 
after lithotomy, 604, 681. 
from uterine flexions, 760. 
with retained testicle, 568. 
Sternum, dislocation of bonis 
of, 39. 
excision of, 226. 
Stertor during anaesthesia. 286. 
Stiffness as a sign of coxalgia, 
163. 
Stomach, fluids introduced into, 
by gravity, 1035. 
by nasal tube, 1034. 
by oral tube, 1034. 
treatment of poisons in. 1033. 
Stomach-pump, evacuation of 
fluids with, 1035. 
introduction of fluids by, 
• 1034. 
Stone in bladder, 629. 
simulated by phimosis, 427. 
treatment of, 648, 651, 662, 
Stools flattened from hyper- 
trophied prostate, 502. 
Strabismus in cervical injuries, 
856. 
Strangulation, priapism in, 438. 
Strangury in cystitis. 528. 
Stricture, division of, in para- 
phimosis, 431. 
of oesophagus, 1019. 
of urethra, 476. See Urethra, 
of vagina, 734. 
Strongylus gigas in kidney, 709. 
Structural changes after arthri- 
tis, 152, 155, 158. 
after old dislocations, 21, 
64. 
in htematoeele, 580. 
in hydrocele, 570. 
in varicocele, 564. 
Struma causing Pott's disease, 
870. 
theories of, 150. 
Strumous arthritis, 158. 
orchitis, 587. 
periostitis, 949. 
Strychnine-poisoning, 1034. 
Stump, bone-changes in. 317. 
bulbous nerves in, 317. 
closing of. 313. 
conical, 321. 
cradle for, 316. 
degeneration of, fatty, 323. 
fibrous, 323. 
malignant. 323. 
depression of, in amputations, 
315. 
dressing of. daily, 317. 
first, 316. 
neuralgia of, 321. 
of penis, 433. 
of tongue, treatment of, 918. 
painful, 318. 
spasm of, 318. 1062 
INDEX TO VOLUME II. 
Stump, structure of, 317. 
vessels, changes in, 317. 
Subastragaloid amputation, 358. 
dislocation, 123. 
Subclavicular dislocations, 54. 
Subcoracoid dislocations, 54. 
Subcutaneous osteotomy, 145. 
puncture of hydrorachis, 853. 
scarifications in congenital 
dislocations, 33. 
Subglenoid dislocations, 53. 
Subglossitis. 994. 
Sublingual gland, carcinoma of, 
995. 
cysts of, 993. 
partial excision of, 994. 
Subluxations, 17. 
Submaxillary gland, adeno-sar- 
coma of, 995. 
anatomical boundaries of, 
995. 
calculi in, 996. 
carcinoma of, 995. 
cystic growths of, 995. 
enchondroma of, 995. 
Subperiosteal excision, 186, 218, 
242, 249. 258. 
Subpubic dislocations, 102. 
Subspinous dislocations of hu- 
merus, 55. 
Suffocation from foreign bodies 
in oesophagus, 1014. 
Sugar in urine, 622. 
Sulphuric acid in white swell- 
ing, 190. 
poisoning, 1033. 
Sunburn, 423. 
Superior maxilla, diseases of, 
957. 
Supernumerary digits, amputa- 
tion of, 296. 
Suppression of urine after li- 
thotomy, 681. 
Suppuration. See Abxeens. 
Supra-cotyloid dislocations, 
102. 
Supra-pubic lithotomy, 664, 
690. 
in females, 695. 
Surgical diseases of women, 716 
-836. 
fever, 384. 
Suspension in dislocations, 117. 
in excisions, 236. 
Suspensory bandage in varico- 
cele, 565. 
of adhesive plaster, 565. 
Suture, shot, in vesico-vaginal 
fistula, 747. 
Symphysis pubis, absence of, in 
epispadias, 452. 
Syncope, death from, under 
chloroform, 288. 
under bichloride of methy- 
lene, 289. 
during catheterization, 507, 
555. 
during venesection, 267. 
from blood- or nerve-exhaus- 
tion, 273. 
treatment of, 273. 
Synostosis, 141. 
Synovia, false anchylosis from 
lack of, 141. 
Synovial membrane, changes of, 
in arthritis, 152. 
in rheumatoid arthritis, 
158. 
Synovial membrane, fibroid for- 
mations in, 147. 
granulations upon, 153. 
inflammation of, 137. 
thickening of, 152. 
Synovitis, 137. 
causes of, 137. 
chronic, 139. 
hydrarthrosis in, 138. 
ligaments changed in, 139. 
symptoms of, 138, 139. 
treatment of, 139. 
fungoid granulation in, 187, 
191. 
gonorrhoea], 474. 
movable bodies after, 127. 
passive, 140. 
passive motion after, 139. 
pathology of, 138. 
pysemic, 390. 
symptoms of, 137. 
syphilitic, 14 0. 
treatment of rheumatic, 138. 
of traumatic, 138. 
with strumous arthritis, 165, 
187. 191. 
Syphilitic enlargement of sper- 
matic cord, 559. 
lip, diagnosis from epitheli- 
oma of. 895. 
orchitis, 586. 
pharyngitis, 1008. 
sarcocele, 586. 
synovitis, treatment of, 140. 
warts on penis, 438. 
on labia, 721. 
Syphiloderm upon hack, 839. 
Syringe, Davidson's, attached 
to catheter, 669. 
deep urethral, 472. 
Teeth, extraction of, anajsthet- 
ics in, 933. 
breaking of alveolus to aid 
in, 934. 
circumstances demanding, 
931. 
instruments for, 931. 
of roots of, 934. 
fracture of, 926. 
fusion of roots of, 936. 
hard tumors of, 937. 
hypertrophy of, 937. 
irregularity of, 925. 
treatment mechanically, 
925. 
tendency to loosen dur- 
ing, 926. 
loosening of, in the aged, 927. 
necrosis of, 927. 
tumors of, 937. 
wisdom-, difficult eruption of, 
928. 
extraction in. 929. 
Temperature after spine in- 
juries, 855. 
during shock, 376. 
Temporo-maxillary joints, noisy 
movements of, 17, 37. 
spontaneous luxation at, 37. 
Tenderness in white swelling, 
186. 
Tendons, changes of, in rheu- 
matoid arthritis, 158. 
contraction of, after amputa- 
tion, 323. 
disposal of, in amputation, 
313. 
preserved in excision of 
wrist, 220. 
Tenesmus, vesical and rectal, in 
calculus, 642. 
Tenotomy after amputations, 
Chopart's, 358. 
of leg, 364. 
Pirogoff"s, 360. 
in anchylosis, 142. 
fibrous, 183. 
in cleft palate, 975. 
in dislocations, 27. 
compound, 29. 
congenital, 33. 
of knee, 115. 
of astragalus. 122, 123. 
of foot, 116, 117. 
of thumb, 85. 
old, 32. 
of elbow, 73. 
subastragaloid, 124. 
in excision of calcaneum 
with astragalus, 259. 
of knee, 235. 
in malpositions, 162. 
in strumous arthritis, 161. 
Testis, 567. 
absence of, 567. 
affections of tunics of, 567. 
anomalies of position of, 568. 
sterility in, 568. 
atrophy of, 597. 
senile, 597. 
calcareous deposits in, 594. 
cancer of, 590. 
cystic, 593. 
dermoid cysts of, 598. 
diseased, in hydrocele, 571. 
encephaloid of, 590. 
diagnosis from cystic, 593. 
from hydrocele, 573. 
T. 
Table, operating-, 272. 
Tampon, air-bag, in lithotomy, 
678. 
arrest of hemorrhage by, 273. 
Tapping of bladder, 512. 
of hydrocele, 573. 
of ovarian cysts, 800. 
Tarsus, amputations through, 
353. 
dislocations of, 121. 
excision of, 255-260. 
Tartar upon teeth, 920. 
Tartar emetic in reduction of 
dislocations, 24. 
Taxis in inversion of uterus, 
764. 
Teale's method of amputation, 
306. 
Teeth, affections of, 923. 
artificial, causing hypertro- 
phied gums, 919. 
broken in extraction of, 934. 
caries of, 927. 
habits as a cause of, 927. 
predisposing to phosphor- 
necrosis. 952. 
dislocation of, 926. 
enamel, abrasion or denuda- 
tion of, 926. 
nodules upon, 937. 
exostosis of, 937. 
extraction of. 931. 
accidents following, 936. 
alveolar necrosis after, 950. INDEX TO VOLUME II. 
1063 
Testis, encephaloid, diagnosis 
from sarcomatous, 592. 
from syphilitic, 590. 
from tubercular, 590. 
morbid anatomy of, 590. 
mortality in, 591. 
statistics of, 590. 
symptoms of, 590. 
treatment of, 591. 
enchondroma of, 594. 
entozoa in, 598. ' 
excision of, 580, 589, 591, 592, 
594, 598. 
fibroma of, 595. 
fungus of, 589. 
hernia of, 588. 
hypertrophy of, 597. 
inflammation of, 581. 
after gonorrhoea, 469. 
forms of, 581. 
in mumps, 997. 
irritable, or hyperaesthetic, 
595. 
lymphadenoma of, 593. 
melanosis of, 591. 
myoma of, 594. 
neuralgia of, 595. 
castration for, 597. 
treatment of, 596. 
position of, in hydrocele, 572. 
in scrotal wounds, 515. 
retained, 568. 
as cause of inguinal hydro- 
cele, 577. 
diagnosis of, 569. 
orchitis in, 584. 
treatment of, 569. 
sarcoma of, 592. 
diagnosis from encepha- 
loid, 592. 
histology of, 592. 
prognosis in, 592. 
strapping of, 583. 
supernumerary, 568. 
Tetanus after operations, 279. 
death from, in burns, 415. 
in compound dislocations, 28. 
traumatic, non-amputation 
in, 296. 
Thecal abscess, death from in- 
cision of, 274. 
Thigh, amputations of, 368. 
dislocations of, 89. 
excision of, 253. 
Thomas's apparatus, 189. 
Thorax penetrated by humerus, 
66. 
Thrombic theory of traumatic 
fever, 387. 
Thrombus, pudendal, 717. 
Thrush, 910. 
Thumb, dislocations of, 83, 87. 
excision of, 225. 
evulsion of, in reducing lux- 
ation, 85. 
Thyroid dislocations, 98. 
Tibia, excision of, 254. 
function of, 254. • 
Tibio femoral dislocations, 111. 
Tissues, change of, after arthri- 
tis, 152. 
after dislocations, 21, 22. 
post-mortem appearance of, 
in erysipelas, 407. 
Toes, dislocation of, 126. 
excision of, 260. 
supernumerary, amputation 
of, 296. 
Tongue, 904. 
ablation of, 916. 
after-treatment, 918. 
buccal, or Jordan's method, 
918. 
mortality after, 918. 
oral method, 916. 
speech after, 919. 
submental, or Kegnoli's 
method, 917. 
modified, by Nunneley, 
918. 
symphyseal, 916. 
abscess of, 909. 
sublingual, 909. 
absence of, 904. 
adhesions of, 904. 
angeiomata of, 911. 
atrophy of, 906. 
bifid, 904. 
carcinomata of, 912. 
contra-indications for oper- 
ation upon, 913. 
division of lingual nerve in, 
. 913. 
duration of, 912. 
sex in, 912. 
treatment by 5crasement, 
915. 
by knife, 914. 
by ligature, 914. 
by thermo-cautery, 916. 
by total ablation, 916. 
cystomata of, 911. 
enchondromata of, 912. 
epitheliomata of, 912. 
diagnosis from syphilitic 
ulcer, 913. 
fibromata of, 911. 
fissured, 908. 
gummata of, 912. 
hypertrophy of, 905. 
inflammation of, 907. 
lipomata of, 911. 
papillary disease of, 908. 
papillomata of, 910. 
polypi of, 912. 
tumors of, 910. 
ulcers of, 909. 
aphthous, 910. 
dyspeptic, 909. 
strumous, 910. 
syphilitic, 910. 
tubercular, 910. 
wounds of, 908. 
Tongue-tie, 904. 
Tonsil, abscess of, 992. 
atrophy of, 991. 
calculi in, 985. 
carcinoma of, 993. 
cystoma of, 992. 
fibroma of, 992. 
foreign bodies in, 985. 
hypertrophy of, 987. 
evil effects of, 987. 
excision in, 989. 
hemorrhage after, 991. 
pathology of, 988. 
relation of, to carotid ar- 
tery, 991. 
symptoms of, 987. 
inflammation of, 985. 
inspissated secretion in, 985. 
lymphoma of, 992. 
parasitic cyst of, 985. 
relation of, to carotid artery, 
987. 
sarcoma of, 993. 
Tonsil, ulceration of, 991. 
Tonsil-guillotine, 990. 
Tonsillitis, 985. 
follicular, 985. 
parenchymatous, 985. 
treatment of, 986. 
Tonsillitome, 990. 
Toothache, 929. 
Tour de maitre, 554. 
Tourniquet, abdominal, in am- 
putations, 324. 372. 
invention of, 300. 
of Petit, in amputations, 309, 
344. 
position of, in foot-amputa- 
tions, 355. 
use of, by laity, 351. 
Tracheotomy in croup, anaes- 
thetics in, 283. 
in laryngeal erysipelas, 412. 
in scalds of pharynx, 1010. 
in retro-oesophageal abscess, 
1019. 
Transfusion in shock from hem- 
orrhage, 382. 
Transudations causing disloca- 
tions, 19. 
Traumatic infective fever, 383. 
complicated, or pyaemie, 385. 
diagnosis from erysipelas, 
394. 
from hectic fever, 394. 
from intermittent fever, 
394. 
from primary abscess, 394. 
from pneumonia, 394. 
from rheumatism, 395. 
from simple surgical fe- 
ver, 394. 
effects of pus in blood in, 
387. 
emaciation in, 393. 
embolic theory of, 387. 
examination of blood in, 
391. 
hay-like odor in, 393. 
hectic fever in, 392. 
metastatic abscesses in, 
389, 393. 
miasmatic origin of, 388. 
morbid anatomy of, 389. 
after early death from, 
391. 
predisposing causes of, 391. 
prognosis in, 395. 
prophylaxis in, 395. 
purulent theory of, 385. 
septicaemia theory of, 389. 
symptoms of, 391. 
of secondary deposits in, 
393. 
temperature record in, 392. 
thrombic theory of, 387. 
treatment of, 395. 
secondary, 385. 
simple, 384. 
after lithotrity, 660. 
treatment of, 384. 
Traumatism causing Pott's dis- 
ease, 870. 
Trismus, diagnosis from luxa- 
tion, 36. 
Trochanter major, excision at, 
253. 
Trough-shaped splint in com- 
pound dislocations, 30. 
Truss in congenital hydrocele, 
561. 1064 
INDEX TO VOLUME II. 
Tube-casts in nephritis, 698. 
in urine, 620. 
Tubercle of bladder, 550. 
of ovaries, 814. 
Tubercular orchitis, 587. 
Tuberculosis, renal, 710. 
Turpentine, retention of urine 
from, 511. 
Tumors, benign, amputation 
for, 294. 
causing spinal curvature, 862. 
dentigerous, solid, 940. 
fibrous, diagnosis from inver- 
sion of uterus, 764. 
of gums, 921. 
of antrum, 960. 
of bladder. 546. 
of hard palate, 979. 
of jaw, lower, 955. 
osseous. 964. 
upper, 960. 
of lip, 892. 
of ovaries, 793. 
of parotid gland, 998. 
of pharynx, 1013. 
of pulp-cavities, 921. 
of scrotum, 519. 
of soft palate, 983. 
of spermatic cord, 558. 
of spinal cord, 848. 
of teeth, 937. 
of tongue, 910. 
of tonsil, 992. 
of urethra, 458. 
of uterus, 766. 
of vulva, 722. 
over parotid gland, 999. 
polypoid, diagnosed from in- 
version of uterus, 764. 
post-maxillary, 974. 
Tunica vaginalis testis, hasma- 
tocele of, 579. 
hydrocele of, 570. 
Typhoid state in anthrax, 400. 
in erysipelas, 405. 
Urethra, dilatation of, 481. 
of lacunae of, 487. 
falsepassages in, 440, 487. 
foreign bodies in, 453. 
from within outward, 453. 
removal by crushing, 
456. 
by incision, 456. 
by instruments, 454. 
obstructed by stricture, 
456. 
from without, 457. 
inflammation of, 459. 
specific, 460. 
laceration of, 440. 
catheterization in, 440. 
location in prognosis of, 
440. 
overlooked, 440.. 
retention of urine after, 
443. 
perineal incision in, 442. 
malformations of, 450. 
multiple meatus in, 450. 
neuralgia of, 475. 
treatment of, 476. 
with anal fissure. 476. 
normal, curve of, 551. 
simulating stricture, 480. 
suction power of, 457. 
of female, 825. 
absence of, 825. 
dilatation of, in calculus, 
696. 
fibro-vascular tumors of, 
826. 
hypertrophy of papillse of, 
826. 
inflammation of, 825. 
granular, 826. 
specific, 738. 
lacerations of. 825. 
obliteration of, 825. 
polypoid tumors of, 826. 
sloughing of, 825. 
rule for capacity of, 482. 
rupture of, 481. 
stricture of, 476. 
annular, 478. 
causing calculus, 632. 
classification of, 477. 
constitutional disturbance 
in, 481. 
cystitis in, 528. 
death from instrumentation 
in, 444. 
from rupture of urethra 
in, 477. 
diagnosis of, 479. 
bulbous bougie in, 480. 
foreign body obstructed by, 
456. 
forked stream in, 479. 
frequency of, 476. 
indurated, 478. 
liable to acute attacks in, 
479. 
membranous, 477. 
mixed, 478. 
neuralgia of testis in, 596. 
number of, 477. 
origin of, 476. 
pathology of, 478. 
permanent incurability of, 
482. 
position of, 477. 
precluding lithotrity, 653. 
pyelitis from, 699. 
Urethra, stricture of, retention 
of urine from, 509. 
sequel m of, 481. 
spasmodic, 476. 
statistics of, 476, 477. 
symptoms of, 479. 
treatment of, 482. 
hy caustics, 492. 
by dilatation, 483. 
continuous, 487. 
rapid, 489. 
urethral chill in, 485. 
by divulsion, 487. 
objections to, 489. 
by external urethrot- 
omy. 492. 
mortality after, 492, 
493. 
on a guide, 492. 
subcutaneous, 494. 
without a guide, or pe- 
rineal section, 493. 
by internal urethrotomy, 
or incision, 490. 
cases suitable for, 492. 
unfruitfulness from, 604. 
vesical hemorrhage caused 
by, 539. 
tumors of, 458. 
polypoid growths, 458. 
vascular growths, 459. 
villous, or papillomatous 
growths, 459. 
wounds of, 439. 
suturing, 442. 
Urethral chill after instrumen- 
tation, 485. 
fever, 444. 
pyaemia after, 446. 
treatment of, 445. 
fistula, 446. 
adhesions in, 448. 
calcareous incrustation of, 
448. 
callous walls of, 447. 
habits influencing, 450. 
prognosis in, 447. 
treatment by astringents, 
448. 
by cauterization, 447. 
by operation, 448. 
hemorrhoids, 826. 
lithotomy in female, 694. 
surgery, preliminary treat- 
ment in, 445. 
Urethra-metre, 483. 
Urethritis, 459. 
granular, 471. 
in female. 825. 
specific, 460. See Gonorrhoea. 
Urethrocele, 827. 
Urethroplasty, 449. 
causes of failure of, 449. 
perineal section in, 449. 
statistics of, 449. 
Urethro-rectal fistula, 449. 
Urethro-vaginal fistula, 743. 
Uric acid causing urethritis, 459. 
in urine, 623. 
Urinal for exstrophy of bladder, 
613. 
for stump of penis, 434. 
Urinary calculus, 629. See Cal- 
culus. 
concretions, 640. 
fibrinous, 640. 
of blood, 640. 
silicious, 640. 
u. 
Ulcer of duodenum in burns, 
415. 
of tongue, 909. 
rodent, of vagina, 737. 
sloughing, of gums, 920. 
Ulceration, amputation for, 294. 
of bladder, from calculus, 647. 
phagedmnic, of vagina, 825. 
vesico-vaginal fistula from, 
647, 742. 
Ulna, dislocation of, 70. 
excision of, 252. 
Undeseended testis, 568. 
Unilocular ovarian cysts, 793. 
Uranoplasty, 979. 
arrest of hemorrhage in, 980. 
Urates in urine, 623. 
Ureter, dilatation of, in hyper- 
trophied prostate, 503. 
in hydronephrosis, 703. 
packed with calculi, 684. 
sacculated, in stricture, 482. 
Urethra, absence of, 450, 452. 
bulb of, wounded in lithot- 
omy, 685. 
cauterization of, in sperma- 
torrhoea, 608. 
in granular gleet, 472. 
congenital obstruction of, 450. INDEX TO VOLUME IL 
1065 
Urinary concretions, urostea- 
lithic, 640. 
deposits, 623. 
carbonate of lime, 628. 
cystine, 628. 
treatment of, 629. 
oxalate of lime, 625. 
phosphates, 627. 
treatment of, 628. 
urates, 623. 
treatment of, 625. 
uric acid, tests for, 623. 
fistula after wounds, 439. 
Urine, 615. 
albuminous, in nephritis, 699. 
tests for, 618. 
alkalinity of, after standing, 
618. 
ammoniacal, in urethral stric- 
ture, 479. 
bile in, tests for, 623. 
blood in, sources of, 620. 
tests for, 619. 
changes of, in calculus, 642. 
in hypertrophy of prostate, 
502. 
in spine injuries, 854. 
decomposition of, in cystitis, 
527. 
density of, 617. 
effect of, upon vagina, 749. 
epithelium in, 620. 
extravasation, treatment of, 
443. 
frequency of voiding, 617. 
impeded by prostate, 502. 
incontinence of, 543. 
after closure of vesico-va- 
ginal fistula, 748. 
after lithotomy, 681. 
after urethral lithotomy, 
695. 
after urethrocele, 827. 
age, as to frequency of, 543. 
causes of, 544. 
from phimosis, 427. 
in hydronephrosis, 704. 
in inmates of homes, 545. 
in Pott's disease, 873. 
pruritus vulvas from, 724. 
treatment of, 545. 
in pyelitis, 700. 
in renal cancer, 712. 
in scrotum, 515. 
normal, 615. 
composition of, 616. 
di nsity of, 616. 
odor of, 616, 617. 
reaction of, 616, 617. 
pathological changes in, 616. 
pus in, tests for. 619. 
quantity voided in twenty- 
four hours, 617. 
reaction of, in nephritis, 698. 
residual, in paralysis, 543. 
retention of, 507. 
after lithotomy, 679. 
after operations, 279. 
after wounds of urethra, 
443. 
aspiration of bladder in, 
444. 
causes of, 507. 
in female, 555. 
death from, 507. 
diagnosis of, catheterism 
in, 507. 
dribbling in, 507, 542. 
Urine, retention of, from en- 
larged prostate, 509. 
from urethral stricture, 479, 
509. 
from uterine tumors, 511. 
from vesical coagula, 508. 
forced catheterization in, 
512. 
hysteroidal, 511. 
in gonorrhoea, 468. 
in prostatitis, 495. 
obstructive, 541. 
spasmodic, 511. 
symptoms of, 507. 
tapping of bladder in, 512. 
treatment of, 509. 
saccharine, tests-for, 622. 
spermatozoa in, 621. 
suppression of, after lithot- 
omy, 681. 
after lithotrity, 661. 
after operations upon ure- 
thra, 444. 
to prevent extravasation of, 
in wounds of urethra, 441. 
tube-casts in, 620. 
propriety of operations 
when found, 621. 
Urostealithic concretions, 640. 
Uterine disease with pseudar- 
thritis, 204. 
tumors, retention of urine 
from, 511. 
Utero-vesieal fistula, 749. 
Uterus, 750. 
anteversion of, 758. 
carcinoma of, 777. 
encephaloid, 777. 
epithelial, 778. 
sexual life influencing, 
777. 
treatment of, 779. 
cysto-fibromata of, 773. 
displacements of, cystitis 
from, 827. 
elongation of cervix of, 780. 
examination of, digital, 750. 
instrumental, 751. 
extirpation of, 780. 
by elytrotomy, 781. 
by laparotomy, 780. 
statistics of, 781. 
fibro-cysts of, diagnosis from 
ovarian, 795. 
flexions of, 759. 
hydronephrosis with, 703. 
inversion of, 763. 
amputation in, 765. 
diagnosis of, 764. 
treatment of, 764. 
laceration of cervix of, 762. 
evil effects after, 762. 
treatment of, 763. 
myo fibromata of, 766. 
diagnosis of, 768. 
pathology of, 767. 
signs of, 767. 
sponge-tents used in, 768. 
treatment of, 769. 
by ecrasement, 771. 
by electrolysis, 769. 
by enucleation, 770. 
by incision of capsule, 
772. 
by laparotomy, 772. 
of submucous, 770. 
of subperitoneal, 772. 
polypus of, 773. 
Uterus, polypus of, diagnosis 
from prolapsus vaginae, 736. 
prolapse of, 753. 
in lacerated perineum, 727. 
retroversion of, 755. 
rupture of, 836. 
sarcoma of, 779. 
sound for, 752. 
specula for, 752. 
tumors of, 766. 
diagnosis from extra-uter- 
ine pregnancy, 833. 
Uvula, elongation of, 981. 
hypertrophy of, 981. 
oedema of, 981. 
removal of, 982. 
voice after, 982. 
v. 
Vagina, absence of, 733. 
atresia, acquired, 734. 
congenita), 733. 
discharges from, in children, 
738. 
double, 732. 
epithelioma of, 737.- 
fissure of, 736. 
fistula of, into bladder, 740. 
into uterus, 750. 
imperforate, menses retained 
by, 735. 
incomplete, 733. 
inflammation of, 738, 740. 
malformations of, 732. 
prolapse of, 736. 
differential diagnosis of, 
736. 
treatment by astringents, 
736. 
by mechanical support, 
737. 
by operation, 737. 
rodent ulcer of, 737. 
stenosis of, 733. 
acquired, 733. 
stricture of, 734. 
tumors of, 737. 
cystic, 737. 
fibrous, 737. 
papillomatous, 737. 
ulcers upon, 736. 
Vaginal lithotomy, 695. 
specula, 751. 
Vaginismus, 725. 
treatment by dilatation, 725. 
by incision, 726. 
Vaginitis, granular, after gon- 
orrhoea, 740. 
specific, 738. 
Varicocele, 562. 
atrophy of testis in, 597. 
causes of, 563. 
diagnosis from hydrocele, 573. 
from scrotal hernia, 564. 
side mostly affected with, 562. 
structural changes in, 564. 
symptoms of, 563. 
treatment of, mechanically, 
564. 
operatively, 566. 
Varicose veins of labium, 720. 
of scrotum, 516. 
Varix, aneurismal, after ampu- 
tations, 323. 
of bladder, 537. 
of oesophagus, 1024. 
of scrotum, 516. 1066 
INDEX TO VOLUME II. 
Vascular growths of urethra, 
459. 
Vas deferens, anomalies of, 567. 
rupture of, 557. 
Vaso-motor paralysis in spine 
injuries, 856. 
Veins, enlarged, in white swell- 
ing, 186. 
entrance of air into, 277. 
excision of, in varicocele, 567. 
purulent absorption by, 385. 
rupture of axillary, 65. 
varicose, of labia, 720. 
of scrotum, 516. 
Velpeau's bandage, 47, 51, 62, 
246. 
Velum palati, affections of, 983. 
Venery, atrophy of testis in, 
597. 
causing hypertrophied labia, 
719. 
pruritus vulvas from, 724. 
Venesection, 265. 
affections following improper, 
265. 
anatomy of bend of arm in, 
265. 
at bend of arm, 266. 
in dislocations, 24. 
of sternal bones, 40. 
in erysipelas, 410. 
inflammation after, 267. 
instruments for, 266. 
in shock, 382. 
on leg, 267. 
. oblique incision in, 266. 
syncope during, 267. 
Venous stasis about strumous 
joints, 159. 
Ventilation, necessity of, in sur- 
gery, 271. 
in pyaemia, 395. 
Vermale's amputation, 304. 
Vertebra prominens, 860. 
Vertebrae, absorption of, in lat- 
eral spinal curvature, 863. 
changes of, in posterior spinal 
curvature, 867. 
dislocation of, 40. 
necrosis of, in Pott's disease, 
871. 
Vesical catarrh, 528. 
fistula after pelvic abscess, 
820. 
hemorrhage, 537. 
after distention, 507. 
diagnosis of, 538. 
vicarious, for hemorrhoids, 
538. 
for menstruation, 538. 
treatment of, 539. 
incrustations, delaying the 
extraction of stone, 675. 
irritation in hypospadias, 451. 
neurosis, 534. 
bladder, education in, 536. 
treatment of, 535. 
papillomata, cystitis from, 827. 
Vesical polypi, cystitis from, 
827. 
tenesmus, 642. 
Vesicles, treatment of, in burns, 
418. 
Vesico-utero-vaginal fistula,750. 
Vesico-vaginal fistula, 740. 
after-treatment of, 747. 
removal of sutures in, 
747. 
self-retaining catheter in, 
747. 
artificial prolapse of uterus 
in, 749. 
causes of, 742. 
characteristics of, 743. 
classification of, 743. 
complicated by location, ex- 
tent, and structure of, 
748. 
obliteration of urethra in, 
825. 
operation for, 744. 
causes of failure of, 
748. 
instruments for, 744. 
introduction of sutures in, 
746. 
preparatory treatment 
for, 743. 
sequelm of, 748. 
symptoms of, 743. 
Vessels, changes of, in stumps, 
317. 
laceration of, in dislocations, 
21, 29, 32, 53, 190, 1 15. 
Vicarious function of kidney in 
burns, 417. 
hemorrhage from bladder, 
538. 
Virus, gonorrhoeal, 460. 
Viscera, post-mortem appear- 
ance in erysipelas, 407. 
thoracic, displaced in spinal 
curvature, 863. 
Vomiting after chloroform, 288. 
after ether, 286. 
rupture of oesophagus during, 
1017. 
Vulva, follicular disease of, 719. 
gangrene of, 718. 
inflammation of, 718. 
abscess after, 718. 
after gonorrhoea, 739. 
cysts after, 718. 
oedema of, 717. 
pruritus of, 724. 
tumors of, adipose, 722. 
cystic, 723. 
fibrous, 722. 
myxomatous, 723. 
sebaceous, 722. 
Water-bed in spine injuries, 859. 
Wheel-crutch in congenital lux- 
ations, 107. 
White swelling, 186. 
Windlass, Gilbert's rope, 25. 
Wire breeches in excision of 
hip, 230. 
Wire splint, 120. 
Wisdom-teeth, difficult eruption 
of, 928. 
reflex anchylosis of jaw from, 
947. 
Women, surgical diseases of, 
716-836. 
Wounds, approximation of 
edges of, 274. 
changes of, in erysipelas, 404. 
complicating dislocations, 28. 
demanding amputation, 293. 
enlarged, to reduce compound 
dislocations, 29. 
erysipelas after, 403. 
glazing of, 273. 
gun-shot, excision of elbow 
for, 219. 
of hip for, 231. 
of knee for, 238. 
of shoulder for, 216. 
of wrist for, 224. 
mortality of amputation 
after, 371. 
incrusted, after lithotomy, 
682. 
of back, 837. 
of bulbous arteries in lithot- 
omy, 676. 
of bulb of urethra in lithot- 
omy, 685. 
of clitoris, 723. 
of corpus spongiosum, 439. 
of joints, 134. 
of labia, 716. 
of lip, 891. 
of oesophagus, 1017. 
of palate, 983. 
of penis, 424, 438. 
of pharynx, 1010. 
of spinal cord, 844. 
of tongue, 908. 
of urethra, 439. 
rest, for healing of, 274. 
Wrist, amputation at, 338. 
for compound dislocation at, 
80. 
dislocation at, 78. 
excision of, 220. 
strumous disease of, 202. 
Xanthic oxide, 637. 
Warts on labia, 721. 
on penis, 438. 
W. 
Y ligament in dislocations of 
hip, 91. 
Y. 
END OF VOL. II. Page 74, last line, insert " anteriorly" after " radius." 
" 95, 11th line from top, for "abduction" read "adduction." 
" 220, 14th line from foot, for "ulna" read "radius." 
" " 11th line from foot, omit "on the ulnar side." 
" " 9th line from foot, for "outer" read "ulnar." 
ERRATA.